539HOSPITAL MEDICINE AND SURGERY.

bowel, the lower end of the ileum and the ascendingcolon were clamped by pieces of rubber drainage tubingpassed through the holes and tied round the bowel suf-

ficiently firmly to occlude its calibre. The bowel wasthen divided transversely with scissors on either side ofthe tumour, and the whole of the caecum, the vermiform

appendix, and the enlarged gland attached were removed.The mucous membrane of the respective divided ends ofbowel were then carefully inverted with a probe, and theserous coat was closed over the section by means of numerouspoints of Lembert’s suture. When this had been done so asto thoroughly close the divided ends the rubber tubes,which acted as clamps, were removed, and the holes inthe mesentery were united as well as the divided edgesof the mesocolon. Incisions about an inch in length werethen made in the longitudinal axis of the bowel on the sideopposite to the mesenteric attachment, each incision beingabout two inches from the divided and now closed ends.Into these openings Senn’s decalcified bone plates (whichMr. Walsham had brought with him in anticipation of theiruse) were inserted and secured ; the serous surfaces aroundthe openings into the bowel were then scarified lightly with aneedle so as to favour their adhesion by plastic exudation,and the margins of the openings were brought into correspon-dence by uniting the sutures attached to the plates, the twolateral threads passing through the wall of the intestineon either side of the opening. As an additional security arow of Lembert’s sutures were put at intervals all round, andone of the appendices epiploiem was sutured to the coats ofthe bowel opposite the junction in order to act as an omentalgraft. The surrounding peritoneum and site of the operationwere then thoroughly cleansed and dried, and the wound inthe abdominal walls was united by carbolised silk sutures, salalembroth gauze and wool dressings being applied. The

operation lasted an hour and three-quarters, during whichthe patient was most carefully kept under chloroform by Dr.D. T. Playfair, Dr. Chatterton assisting Dr. Ilott and Mr.Walsham. The patient stood the operation fairly well, butwas suffering greatly from shock at its close. Opium was givenin doses of fifteen minims of the tincture three times in thefirst twenty-four hours. She did not suffer from sickness,but was troubled by flatus. At 6.30 P.M. the pulse was 108,and the temperature 101° F. On July 3rd the pulse was96, the temperature being 100.4°. One grain of opium inpill form was prescribed. On the 5th the bowels acted verycopiously, the motions being partly formed, after which therewas great pain in the abdomen, lasting for about three hours.Opium was again given by the mouth, and laudanum and hotflannels were applied to the abdomen. The patient becamevery collapsed after the action of the bowels, requiring freeadministration of stimulants. There was frequent distressinghiccough, but no vomiting or abdominal distension. Thewounds were inspected and were found to be looking well.The temperature was 101° and the pulse 100. The relaxedstate of the bowels continued. The patient was givenastringent chalk mixture together with opium by the mouth atfrequent intervals, and, as regarded food, she took arrowroot,sago, beef tea, and milk, and port wine and brandy as stimu-lants. On the9th she was ordered pills of sulphate of copperand opium. On the 10th and llth the diarrhoea had ceasedand she was allowed fish, custard pudding, and bread. Onthe 13th she had boiled chicken, and on the 19th she wasplaced on full diet and a pint of stout a day. The wound, whichlooked well at first, had its healing delayed by troublesomesuppuration under the abdominal muscles, the pus burrowinginwards towards. the middle line. This happened after the removal of the sutures and was preceded by local hardness ’iand tenderness. The parts from which the pus came weresyringed out frequently with a warm solution of izal andwere often dressed. Under this treatment the suppura-tion declined, and the wound became soundly healed. On

Sept. 2nd the patient left the hospital and went to Brightonfor a month. She returned looking well and strong and isnow able to walk for considerable distances, looking andfeeling perfectly well. She was seen in November, 1893,by Dr. Ilott, who inspected the abdomen, and the cicatrixwas found to be sound, firm, and soft. Nothing abnormalcould be felt at the site of the operation, and the enlarge-ment of the inguinal glands had subsided.

Description of tkegrewtla by Mr. EDGAR WILLETT (Curatorof the Museum at St. Bartholomew’s Hospital).-The portionof intestine removed weighed altogether six ounces andmeasured four inches in length after hardening ; it consistedof the cascum and vermiform appendix and had a margin of

healthy colon measuring three-quarters of an inch at itsdistal end and a rather narrower margin of healthy ileum at theproximal end. The greater part of this (over three inches)was the seat of a typical malignant ulcer, involving the wholecircumference of the bowel, both sides of the ileo.ccecal valve,and extending slightly into the ileum. The growth had alsoextended into the vermiform appendix for about half an inch.The fat surrounding the bowel was thicker and firmer than isnormally found, and was evidently inflamed, but it was notapparently directly invaded by the malignant growth, nor hadthe omentum or any other viscus formed adhesions. The

specimen is preserved in the museum of St. Bartholomew’sHospital (Series xviii., No. 2027 D.) Microscopical examina-tion showed it to be a typical case of adenoid carcinomawith extensive ingrowths into the muscular tissue of thebowel.Note by Dr. ILOTT.-I desire to record my grateful

thanks to Mr. Walsham, the honorary consulting surgeonto the Bromley Cottage Hospital, for his able suggestions andskilful assistance at each stage of the long and difficultoperation, and also to the above-mentioned colleagues, with-out whose help it could not have been carried out.

COVENTRY AND WARWICKSHIREHOSPITAL.

TRACHEOTOMY FOR DIPHTHERITIC OBSTRUCTION IN A

CHILD TWELVE MONTHS OLD ; RECOVERY ;REMARKS.

(Under the care of Dr. PHILLIPS.)WE commented last year in this department of THE LANCET

on the performance of tracheotomy at an early age, especiallyfor obstruction due to diphtheria. Mr. Parkes in his workon

" Diphtheria " alludes to the case of a child successfullyoperated on by Scontetten for croup. The influence of ageon prognosis after tracheotomy for diphtheria and alliedconditions has been well shown by Messrs. Lovett andMunro in their paper on the results in 327 cases of theoperation. They say: "The age of the patient is, ofcourse, an important consideration; the mortality ratefalls as the age increases up to eight and ten years.In 1600 cases collected from Cohen, Schuller, Birnbaum,

, Martin, &c., and tabulated with regard to the age of thepatients, the recovery rate in children less than two yearsold was 20 per cent., rising steadily until the age of eightyears was reached, when it was 40 per cent. The 327 casesreported here followed much the same course, except in theyoungest children, when the operation proved much morefatal. Of forty-two patients under the age of two yearsonly three recovered-one eleven months old and two fifteenmonths old, all nursing children." They have also given asummary of 21,853 cases of tracheotomy recorded in generalmedical literature, with a mortality of 28 per cent. For thenotes of this case we are indebted to Mr. C. HamiltonWhiteford, house surgeon.A female infant aged twelve months was admitted into the

Coventry and Warwickshire Hospital at 6 P.M. on Dec. 5th,1893, suffering from dyspnoea, with lividity of the face and re-cession of the thoracic parietes on inspiration. The pulse was144, the respiration 52, and the temperature 101° F. Thehistory was that the child had been quite well np to twenty-four hours previously, when it developed an attack of"croup," which rapidly became worse. Chloroform was atonce administered and tracheotomy performed, Parker’stube being used. Marked improvement in the breathingfollowed the operation. Pieces of membrane were coughedup at once on introducing the dilators, and other piecesappeared at intervals during the following week. The tem-

perature, which on admission had been 101°, rose to 104 -2"at 10 A. M. on the following day, after which it steadilyfell, and reaching normal on the fourth day after opera-tion, it did not again rise above 100°. The child wasfed with milk, with one ounce of brandy, one drachmat a time, in twenty-four hours. Fourteen days after theoperation Parker’s inner tube coated with indiarubber wasintroduced, the child breathing both through the woundand the larynx for three hours. Seventeen days after theoperation the tube was removed entirely and the childbreathed without it, chiefly through the wound, for twelvehours, when, breathing becoming laboured, chloroform wasadministered on account of struggling and difficulty in

540 ROYAL MEDICAL AND CHIRURGICAL SOCIETY.vzv

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reintroducing the tube into the wound, which had partlyclosed ; the tube was reinserted. On the thirtieth day afterthe operation the tube was left out entirely, and on the thirty-fourth day the wound was closed and breathing through thenatural channel was completely re-established. Some slighthoarseness of the voice passed off in a few days.Rermarks.-Recovery in children under two years is rare.

The case illustrates the advantages of operation before thepatient has become moribund and of alcohol even for aninfant twelve months old.

Medical Societies.ROYAL MEDICAL AND CHIRURGICAL

SOCIETY.

Cases of Pleurisy caused by the Pneumococcus, and withConstitutional Symptoms resembling those of Pneumonia.-Relationship between Disorders of Digestion and Neur-asthenia.

AN ordinary meeting of this society was held on Feb. 27th,Dr. CHURCH, Vice-President, being in the chair.

Dr. WASHBOURN communicated a paper on cases of Pleurisycaused by the Pneumococcus, and with Constitutional Sym-ptoms resembling those of Pneumonia. He described threecases. In the first case the symptoms were those of

pneumonia, but the physical signs were not characteristicand the sputum was not rusty. The attack began suddenlywith a rigor, and on the tenth day the temperaturehad fallen and the constitutional symptoms had dis-

appeared. The patient was considered to be convalescent,but the physical signs did not clear, and the tempera-ture subsequently rose. An exploration of the chest re-vealed the presence of pus. A drainage-tube was insertedand the patient made a good recovery. The pus was foundto contain the pneumococcus by the usual bacteriologicalmethods. The case was at first considered to be one ofpneumonia followed by an empyema, but looked at it inthe light afforded by the other cases he believed that itwas one of primary empyema. In the second case the con-stitutional symptoms were those of pneumonia, and includedhigh temperature, cough, rapid breathing, delirium, and

herpes. The physical signs, though not typical, were notmore atypical than they often were in pneumonia. The

patient died after a few days’ illness. At the post-mortemexamination the lung was found to be healthy, but therewere fifty-four ounces of pus in the right chest. The puscontained the pneumococcus. In the third case, that of achild, there was double pleurisy with some effusion. Afew ounces of fluid were removed by aspiration, andwere found to contain the pneumococcus. The case

terminated fatally, and at the post-mortem examination bothpleuræ were found to be covered with thick tenaciousfibrin. It was well known that the pneumococcus was themost common cause of croupous pneumonia, and the sameorganism had been found in pleurisy and empyema. Suffi-cient stress had, however, not been laid upon the fact thatthe pneumococcus might produce the same constitutionalsymptoms when invading the pleura as it did when invadingthe lung. Dr. Washbourn believed that the second case showedthat this was true. The third case was of interest, inasmuchas the constitutional symptoms were similar to those of

pneumonia. The patient might have recovered, and the casewould probably have been considered to be one of pneumonia.He believed that many cases diagnosed as pneumonia,but with equivocal signs, were really cases of pleurisycaused by the pneumococcus. He would point out the

importance of exploring the chest in such cases, and wouldurge the necessity of the bacteriological examination of thepus of empyemata, as it was possible that, when due to thepneumococcus, a simple aspiration would be sufficient.-Dr. HALE WHITE said that, in addition to the two cases underhis observation which were recorded in the paper, he had seenfour other cases during the last few months. A man wasbrought to hospital with every sign of pneumonia, therehaving been a rigor, herpes, and rusty sputum, with rapidbreathing and high temperature. A loud rub on the right sideobscured the physical signs. The temperature gradually fellin eight days and he was only slightly better ; it then rose

again and the man died suddenly. At the post-mortem

examination a small empyema was found at the base of theright lung, and pus had soaked into the lung, which was.partly gangrenous. The patient also suffered from malig-nant endocarditis. A girl came into hospital with a fairlytypical history of pneumonia. At the left base there wasmuch dulness, but only a little bronchial breathing. Three-ounces of pus were obtained on aspiration. After elevendays the temperature gradually fell and she died suddenlyin the night. At the necropsy no signs of pneumoniawere found, but there was a thick layer of fibrinouslymph in the pleura, with some turbid fluid. A middle-aged’woman was admitted with marked signs of pneumonia at theleft base, but the area of dulness overshadowed the other-signs. The temperature gradually fell and then began slowly to.mount again. Repeated attempts to find pus resulted in theevacuation of four ounces ; after that she recovered. A boyaged six was admitted with a typical history of pneumonia.The temperature, after falling, began slowly to mount again.Half an ounce of pus was found by aspiration, and after thatthe patient did well. He related other cases to show the asso.ciation of the pneumococcus with empyema, meningitis, andendocarditis, and said that it perhaps explained the associationof jaundice with one case of pneumonia and of retraction ofthe head with another. In those cases of empyema due to,the pneumococcus the signs would not be typically those ofpneumonia, the local signs being especially aberrant : thetemperature usually fell slowly, the physical signs did notclear up readily, and the patient did not seem to be muchbetter after the fall of the temperature. With the furtherrise of the temperature diarrhcea often developed. Thedisease was general, and might affect not.only the pleura,but also the meninges &c. Pericarditis, when it occurred,was due to an infection of the pericardium by the diplo-coccus, and not to simple extension from the pleura, as hadbeen commonly taught. There need not always be pus presentto explain the physical signs, for in one case with the secondrise of temperature there occurred a rigor and a large fibrinousexudation without empyema.-Dr. SANSOM said that it didnot seem to him that influenza had been excluded from thesecases. The bacillus of influenza was very apt indeed to beassociated with other well-known bacilli. Thus, influenza}

pleuro-pneumonia was recognised, and influenza gave remark-able help to the development of tuberculosis. The casesrelated resembled the forms of pneumonia often met witbsince the influenzal epoch, the general symptoms being severe,while the local condition might be atypical. The influenzabacillus, having a tendency to attack nervous structures, dis-turbed the trophic condition of the lungs, and then the pneu-mococcus could develop more exuberantly.-Dr. KANTHACKsaid that it was generally admitted that the pneumococcus wasthe common cause of pneumonia. Since October he had ex-amined fifteen uncomplicated cases of pneumonia, and in allthe pneumococcus of Fraenkel was present; in thirteen it wasin pure culture, and in two others it was associated with thestaphylococcus pyogenes aureus and a streptococcus respec-tively. If the sputum of a patient before the pneumonic crisis.was injected into a rabbit or guinea-pig the animal died frompneumococcus septicæmia, but if sputum taken after the crisis.was injected the animal was rendered immune from pneumo.-coccus infection. He examined a case of purulent meningitisand found the lungs free, but the pus in the cerebral andspinal membranes contained pure cultures of pneumococcus.In a case of ulcerative endocarditis the pneumococcus was.found associated with the staphylococcus albus and aureus; qthe same three organisms were found in embolic abscesses inthe lungs. In a case of purulent peritonitis in a young girland in another of suppurative pericarditis and peritonitis withempyema, in two cases of otitis media, in one of empyemaof the frontal sinus and in one of pneumonia suddenly fatal!and associated with empyema pure cultures of the pneumo-coccus were found.-Dr. CHURCH asked whether any controlexperiments had been performed with the pus from ordinaryempyema to see whether the pneumococcus could be found inthem.-Dr. HALE WHITE, replying for Dr. Washbourne, saidthat pneumococci had been found in the pus of ordinaryempyemata. He said that it was remarkable that the pneumo-coccus often did not produce the toxic symptoms if it wasnot developing in the pleura or lung. People badly affectedwith the toxin of pneumonia were liable to die suddenly.A paper was then contributed by Dr. A. S. ECCLES on

the Relationship between Disorders of Digestion and Neur-asthenia. The definition of Beard that neurastheniais a chronic functional disease of the nervous system,the basis of which is impoverishment of nervous force,