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from the granary, where the occurrence took place, to his bed-room, he was breathing with difficulty; was entirely insensibleduring the time that he lived, which was about a quarter of anhour after his removal and about twenty minutes after he wasextricated from the sack.The jury returned a verdict of "manslaughter" against the

parties implicated in the transaction, and they were committedon the coroner’s warrant for trial at the ensuing assizes.Maldon, May, 1852.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdiscectionum historias, tum aliorum proprias, collectas habere et inter secomparare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14, Proœmium.

ST. BARTHOLOMEW’S HOSPITAL.

Carcinoma of the Rectum; Artificial Anus by Amussat’s method;Temporary Relief; Death; Autopsy.

(Under the care of Dr. BURROWS and Mr. PAGET.)

WE called attention a little time ago to some cases of uncon

querable obstruction of the intestinal canal, which were treated inthis hospital (THE LANCET, vol. ii., 1851, p. 128). It will be reomembered that it was not thought advisable, in these instances,to resort to operative measures, and that on post-mortem exami.nations, a state of parts was found which might in some degreehave justified an attempt of creating an artificial outlet for thepent-up fsecal matter. We have now to offer a few details of acase in which Mr. Paget actually made an artificial anus in the

groin, with temporary benefit; and though the patient did .not

finally recover, it is of importance that such cases should be puiupon record, as it may happen that a similar operation, undeimore favourable circumstances, might prolong life for an inde-finite period.

There is doubtless some risk in making an artificial outlet,either for the fseces or urine, but it has appeared to some ex-perienced surgeons that this risk would perhaps be less im-

portant if such operations were performed earlier, and beforethe patient is completely reduced by pain, peritonitis, and theadministration of strong purgatives, or other medicines. In fact,the question is simply this: is the danger of making an artificialanus or urethra greater in a given instance than allowing theobstruction to continue, relying in the latter case either on theefficacy of remedies or the powers of nature ?

It is clear that in such a disease as carcinoma of the rectum,the patient d;es of the malignant disease, or the obstinate consti-pation to which the cancerous affection may give rise. But thefatal issue is more rapid by the effects of the obstruction than thoseof the cancer, so that in cases of this kind an artificial opening inthe loins may very properly be made.* In intestinal constrictionby band, congestion, fibrinous deposit, or any adventitious changewhich admits of spontaneous repair, or rectification by surgicalmeans, a lumbar anus may be looked upon as a temporaryoutlet, the great advantage of which is to forestall the evileffects of a prolonged retention of fmcal matter, and afford aready exit to it, while the portion of the intestinal canal whichis the seat of the obstruction undergo.-s (in favourable cases)such changes as will tend to re-establish the continuity of thewhole tract.

There is certainly some analogy between puncturing thebladder by the rectum, making an artificial anus in the loins, andperforming tracheotomy. We want, by these* operations, to

facilitate the exit of certain products or the entrance of air, inorder to ward off a fatal issue, these operative measures beingprincipally intended to atford temporary re;ief. But the sur-geon, after following this line of practice, turns his wholeattention to the quiescent state to which the affected organs are

brought by the artificial in- or out-let, and endeavours to take ad-vantage of this truce, if we may so speak, to favour the returnof healthy function in the digestive, urinary, or respiratoryorgans.

* See a case of the same nature treated by Mr. Gay at the Royal FreeHospital. THE LANCET, vol. i., 1851, p. 623.

The great misfortune is, of course, that we are exposed in fatalcases to the displeasure of the patient’s friends, who never fail toattribute to the operation, and not to the disease, the unfavourabletermination which may take place. This injustice on the part ofthe public has very probably induced surgeons in many instancesto postpone operations, which at an early period might have beeninstrumental to the prolongation of life. We refrain from sayingmore just now, for we fu’ly expect having very soon an oppor-tunity of returning to this subject, -which is in several respectshighly important, and proceed to offer a few details of the presentcase, as noted by Mr. Callender, the dresser of the patient.

Sarah P-, about forty-five years of age, was admittedJuly 27th, 1851, into Faith ward, under the care of Dr. Burrows.The patient was in a state of great exhaustion and emaciation;her lips and teeth were covered with sordes, the respirationlaboured, and the skin warm, except towards the extremities ;the pulse was 124, small and soft; the tongue dry, brown on thedorsum, and red at tip and edges; the thirst urgent, and theappetite quite gone. There was no nausea on admission, butthere had been sickness and vomiting on the previous morning;the bowels had been confined for nine days, and no urine voidedfor about twelve hours. On examination, the abdomen wasfound hard, distended, and tympanitic, the integuments coveringit firm and glazed, the cavity being the seat of intense pain,principally referred to the region of the cæcam, and occurringin paroxysms, with violent peristaltic movements of the intestines.In the rectum, a firm tumour was felt projecting into the cavityof the bowel, depressed in the centre, and seemingly springingfrom the hollow of the sacrum. The tumour descended to withinabout four inches of the anal orifice, between which and theabnormal growth the rectum was healthy, but of a larger calibrethan usual. The uterus had been in a prolapsed condition for along time past.The patient, on being questioned, stated that she was a widow,

the mother of two children, that her labours had been natural,and that she generally enjoyed good health, though now andthen, for the last eight years, suffering from constipation. Withinabout one year, the stoos had been scanty, and consisting ofsmall worm-like pieces of faecal matter. The present abdominalobstruction commenced, as the patient says, nine days beforeadmission, but there was reason to believe that eleven days hadpassed since the last, evacuation. She has had violent pain inthe abdomen ever since, and the most active aperient treatmenthas not overcome the constipation.

Dr. Burrows directed the introduction of a long tube, which,however, gave no relief; a drop of croton oil was therefore given.As this had no effect, at seven o’clock in the evening, Dr. Burrowsand Mr. Paget decided, in consultation, that an artificial outletfor the fseoal matter should be made in the loins by opening thecolon.

Chloroform was administered; and while the patient lay onher chest and abdomen, Mr. Paget made an incision over thedescending colon, about four inches in length, and extending fromthe extremity of the last rib to the crest of the ilium. Thelatissimus dorsi, external oblique, lower and outer part of thequadratus lumborum, and the aponeurosis of the internal oblique,were successively divided, and found much thinned by the dis-tention. The intestine was now exposed, and, being very tense,was easily opened by an incision about half an inch in length.A copious discharge of fluid feecal matter and flatus instantly tookplace ; and as the bowel bulged ont considerably ; it was securedto the margins of the external wound by four ligatures, and the

patient conveyed to bed. During the operation, the pulse con-tinued steadily at 112, and rather improved in volume towardsthe conclusion. The patient was given some ether in camphormixture, to be repeated every four hours ; and she was to havean opiate when necessary.

It was found, on the next day, that she had slept tolerably;the wonnd had allowed a constant and copious discharge of fæcalmatter; the patient felt much easier, and had not complained ofpain since the operation; pulse 96, s’ightly decreased in volume;tongue lesi dry, and covered on one side with a thick white fur;appetite slightly returned. The wound looked well, but themucous membrane of the bowel was everted, and projectedthrough the external wound; the herneated membrane was,however, easily returned, and kept in its place by a piece ofsponge. Twenty ounces of high-coloured urine were drawn offby the catheter. The diet was to consist of arrowroot in milk;beef-tea; and wine.The patient was quite free from pain during the whole of this

day, and went on taking a fair amount of nourishment. Therewas no nausea, and partly solid faecal matter continued to be dis-charged from the wound. The abdomen was at the same timeflaccid, and tolerant of pressure.

519

During the second night, the patient lay dozing, and takingfreely the food offered to her; but about six in the morning shebecame very weak, her extremities turned cold, and she com-plained of great faintness. Ten ounces of urine were drawn off,and large quantities of brandy administered; but the patientgradually sank, and died at half-past seven in the morning,thirty-six hours after the operation, without any complaint orexpression of suffering.

Accozcnt of the Post-mortem Examination.-The peritonæalcavity contained five or six ounces of turbid serous fluid; softlymph lay in the grooves between many of the convolutions of theintestinal canal ; a larger quantity of the same lymph was foundin and about the part of the descending colon into which the open-ing had been made, though its periton2eal covering had sustainedno apparent injury. The upper half of the small intestines wasdilated, but not considerably so, with fluid, fsecal matter, and air ;the lower half and the greater part of the large contracted. Thecoats of the whole length of the canal appeared healthy as far asthe middle of the rectum, where, about four inches from theanus, the walls of the intestine were abruptly contracted arounda very hard tumour. The latter, of annular form, appeared tooccupy the whole wall of the bowel for about half an inch, pro-jecting into its canal, and so nearly closing it that a quill couldscarcely be passed. The posterior part of the tumour adheredfirmly to the front of the sacrum, and had to be cut away from it.The whole substance of the growth had the hardness of scirrhouscancer of the breast, and its inner surface was covered with themucous membrane of the rectum, which membrane was soft andswollen, but not ulcerated. The peritonsæal covering of the frontand sides of the rectum was constricted deeply to the substanceof the tumour, and adherent to it. Except this disease of therectum, and the prolapsus of the uterus, no organs presented otherchanges than those usual in old age. The part of the colon intowhich the opening had been made was contracted to its ordinarysize, and the space between the lines of reflection of the peri-toiioeum on its sides was, in this contracted state, rather less thanhalf an inch. The incision into the intestine was situated mid-way between those two lines of reflection of the peritonaeum, there-fore not more than a quarter of an inch from each. The mucousmembrane of this portion of the intestine was turgid with blood,and its peritonmal surface, when the lymph was wiped from it,appeared healthy. The wound presented nothing remarkable.

LONDON HOSPITAL.Abscess of the Lung following Pneumonia; Death; Antopsy.

(Under the care of Dr. PEREIRA.)THE formation of abscess in the lung as a consequence of

pneumonia is considered a very rare occurrence ; but it is pro-bably still more rare to find a circumscribed accumulation of pusin the pulmonary tissue taking on a semi-gangrenous character.Such events seem in some degree to exclude each other; for thevigorous exudation indispensable for hemming in purulent mattercan hardly be contemporaneous with sphacelus of the lung.However this may be, it is plain that in constitutions brought toa state of great debility by excesses, the most unusual patholo-gical phenomena will. spring up ; and these being at all timesinstructive, we shall just, from the notes of Mr. Whitby, relatethe following case :-John A. T-, aged forty, formerly a solicitor, married, and

the father of four children, was admitted, January 18, 1852,under the care of Dr. Pereira. The patient is of a dark andsallow complexion, thin, weak, and exhibiting all the signs of adeteriorated constitution ; his habits have been very intemperate,the chief beverage he indulged in being spirits. His health had,however, been tolerably good, until about five months beforeadmission, when. he was seized with pain in the right side of thechest, increased by a full inspiration ; his habitual cough becamevery troublesome, the expectoration profuse, and of an offensiveodour, pretty similar to that which was noticed on his admission.No melical aid was sought until three weeks since, when rigorshad set in ; which the patient tried to conquer by large potationsof gin-and-water. The pain in the right side of the chest wasthen somewhat relieved by blisters, &c., but he was soon obligedto apply for admission into the hospital.When first seen, the patient complained of cough and abundant

expectoration; his voice was hoarse, the breath very short, thecountenance anxious and sallow, the bowels relaxed, but thE

appetite still good. The tongue was furred and moist, with arunpleasant taste in the mouth; the pulse rapid and small, and thEurine abundant, but very ammoniacal.On examination of the chest, dulness was found over the righ

sub-clavicular and mammary regions, the corresponding pnrts or

the lcft side being resonant: respiratory murmur, indistinct overa great portion of the right side of the chest, both anteriorly andposteriorly, whilst it was puerile on the left. To the right of thecentral part of the sternum a peculiar tremulous sound is heard,which has much resemblance with the pulsation of a large vesselthrough a cavity containing fluid. This souad was not, however,constantly noticed, nor could it be excited by any particularposition of the body. The patient was aware of this peculiarbruit; he could himself imar it, and compared it to the noisemade bv water babbling from the lid of a tea-kettle. The actionof the heart v;as accelerated, but no other irregularity was de-tected. As to the voice sounds, pectoriloquy was heard at thebase of the right scapu’.a. When inquiring about the patient’ssensations, it was found that the right side of the chest was pain-ful, and that the cough was extremely troublesome when he layon his left side, the easiest posture being the slightly raised dorsaldecubitus.

Dr. Pereira ordered bark and ammonia to be taken three timesa day. The symptoms continued pretty well unaltered for thenext few days, during which the patient took, first chlorate ofpotash, and subsequently small doses of sulphate of quinine andmorphia. The sputa remained of the same nature, the perspira-tions at night became very profuse, and the relaxation of thebowels could hardly be restrained by logwood and chalk. Thusthe patient progressed for about three weeks, the amphoric murmuron respiration being audible over the right side of the chest, andthe heart’s action being accompanied by a peculiar gurgling andundulatory sound.

; From the physical signs, and the nature of the symptoms! which had existed previous to the patient’s admission, it was. assumed that he had suffered from pleuro-pneumonia, which had’ resulted in abscess of the lung, with adhesion of its walls to the, parietes of the chest, besides effusion into the cavity of the pleura.

Thus was a tremulous sound produced with each impulse of the. heart, resembling the vibration produced by tapping a phial con-

taining air and fluid. Twenty-six days after admission, the. patient died suddenly, after expectorating a large quantity of. very offensive matter.; Post-rraortem Examination.—On viewing the chest, before pro-, ceeding to the inspection of the thoracic viscera, it was observed,

that the right side was larger than the left, and presented a,

rounded appearance, with the filling up of the intercostal spaces.The thorax, when opened, was found completely filled with pusof a very offensive odour. A large abscess was situated in theright lung, the outer wall of the cavity being adherent to thepleura costalis ; and running in front of the lung, in a transversedirection, was a broad sinus of communication, extending to themiddle mediastinum, which region might be considered as theinternal boundary of the abscess. The substance of the lungcontained a large quantity of mucus, mixed with air and pus, aswell as small tubercles and pieces of lymph. The bronchialtubes were filled with matter similar to that contained in theabscess, and the lung was adherent over its whole surface to theparietes of the chest. The left organ was perfectly healthy, butthe cavity of the pleura contained about five ounces of serum.The heart was pale and of lax fibre, but otherwise in a normalcondition.

It is clear that certain changes in the walls of the abovedescribed abscess, or a decomposition of its secretion, must havegiven rise to the fœtor so characteristic of gangrene. The latterdid not, however, exist in the manner usually seen, namely, acrumbling down of the pulmonary tissue, and a dark livid colourof parts. A circumstance which is finally worthy of record is,that the foetor had existed from the commencement of the purulent secretion.

ST. MARY’S HOSPITAL.Traumatic Stricture of the Urethra; Treatment by Dilatation,

and subsequently by Incision ; Chorea; Death; Autopsy.(Under the care of Mr. COULSON.)

THE present patient laboured under the consequences of asevere injury to the urethra, and presented that melancholyseries of symptoms which is so well known to every practi-tioner. The usual treatment adopted in such cases is to keepthe urethra as pervious as possible by the use of bougies ; en-deacour to overcome retention of urine by the employment ofcatheters ; aud finally, to make an opening in the perinaeum, ifno instrument can be passed. It has certainly struck many asurgeon that this method does not always lead to a cure, and thatit has very often caused great disappointment. The cicatrixwhich forms after a wound of the urethra is so apt to contractover and over again after careful dilatation of the canal, and such

complete changes often oceur in the course and relations of the