in bed, with an inclination towards the left side, so as to favour the escape of matters from the wound. She took a grain of opium immediatetly, and was supplied with small quantities of beef-tea, gruel, and milk. I should, perhaps, remark that chloroform was not administered in this case, on account of the vomiting, which continued even during the operation. There was very little bleeding, and no vessel required a ligature.

January 24th. Feels greatly relieved by the escape of stercoral matter through the wound. This has not been incessant, but has recurred abont every half hour through the night, and has always been preceded by pain in the bowels. Has had no sickness since the operation; has had some sleep, and has been able to take some liquid nutriment frequently. The expression of her face is still anxious, and she seems to be depressed by the frequent recurrence of colic-like pain. Her breathing is easier; her pulse 106, sharp, but stronger than yesterday; her skin is warm; her tongue whitish and moist; her abdomen is somewhat tender, though much lessened in size. She complains of smarting in the wound, which looks well, and is free from inflammatory action.

25th. Took a grain of opium again last night, and slept tolerably. The bowels act through the lumbar aperture about every hour, the approach of the evacuation being indicated by a griping or pinching pain, accompanied by flatulent rumblings. The whole of the fæcal accumulation has not yet been voided, but is escaping, mixed with fresh bilious secretion. To-day she had a scanty discharge per anum, composed chiefly of mucus, but having a little fæcal matter mixed with it. Her pulse has fallen to 90, her tongue is cleaner, and her appetite is increased. The wound looks well.

[On April 18th the patient is stated to have not one bad symptom, and from this time to the end of two years, she remained in the enjoyment of perfect health. Three months ago, however, serious symptoms began to arise, and at this period the condition of the bowel is thus described:]

The rectum remained much the same as at the time of the operation, the bulk of the thickening being perhaps a little increased. Since that time she has suffered an attack of sub-acute peritonitis, and her legs have become cedematous. The abdomen also has increased in size; and her symptoms indicate the probability that the morbid growth in the pelvis which closed the rectum has extended into the abdomen, and is now producing injurious effects upon the contiguous structures.

[A postscript is added to this case, in which it is stated that after the last report the dropsical symptoms rapidly increased, and the patient died on the 10th of February, 1852.]

When the body was examined, three or four pints of turbid serum escaped from the cavity of the abdomen. The peritoneum exhibited the effects of peritonitis; the intestines were glued together, to the omentum, and to a tumour as large as a man's head, which appeared to emerge from the pelvis. This tumour arose from the right ovary, and consisted principally of cerebriform cancer. A section of it displayed grey and white brain-like matter, with patches of ecchymosis here and there. In some parts of it there were cysts filled with the yellowish-brown glue-like matter of colloid cancer, and other cysts from which serum had escaped. In the pelvis another tumour as large as an orange was found. This was the left ovary, in which the same morbid degeneration was going on as in the right. The liver and the mesentery also contained similar deposits. The uterus was healthy. The colon was healthy throughout; below the opening in the left lumbar colon made by the operation, the sigmoid flexure and the rectum were larger than the natural calibre, and contained some ounces of dark-coloured scybalæ. At a distance of about three inches from the anus the rectum was suddenly and completely closed by a dense firm fibrous structure not more than a quarter of an inch in extent; below this part the canal was again pervious down to the anus, but was contracted and empty. The coats of the rectum immediately above the stricture had a healthy appearance, though softer and more lacerable than usual. The artificial opening into the colon in the loin was carefully examined. Its shape was oblong, and its cutaneous margin had a firm cordy feeling. The structures surrounding this orifice, which had given so much trouble by its tendency to contraction, consisted of the skin and a dense fibrocellular membrane. The muscles and fascia of the loins were all traced to within three-eighths of an inch of the margin of the aperature, where they became blended XXVIII.-13.

together, and terminated in a mesh of strong interlacing fibro-cellular fibres, which were intimately connected both with the colon and the integument around the artificial opening.-Medico-Chirurg. Transactions, 1852, p. 226.

91.—TWO CASES OF INTESTINAL OBSTRUCTION,

IN WHICH THE OPERATION FOR THE FORMATION OF AN ARTIFICIAL ANUS WAS PERFORMED; ONE IN THE ASCENDING, AND THE OTHER IN THE DESCENDING COLON. By WILLIAM JAMES CLEMENT, Esq., Shrewsbury.

[On the 8th of October, 1841, in consultation with Mr. Dovaston, Mr. Clement visited Mrs. Gough, aged forty-seven, labouring under symptoms resembling those of strangulated hernia. For 14 days no evacuation from the bowels had been obtained in spite of various purgative remedies and enemas. A drop of croton oil every two hours along with turpentine enemas were now prescribed. No relief whatever was obtained, and at a subsequent meeting, says Mr. Clement:]

I carefully examined all the parts likely to be the seat of hernia, and also the rectum, which freely admitted O'Beirne's tube to the extent of fourteen inches. A large quantity of tepid water was injected, but it returned almost colourless; and as the patient was able to retain several pints for some time, I concluded that the cause of obstruction was not in the descending part of the colon.

The vomiting had been very distressing since Friday night. If only a tablespoonful of beef-tea was swallowed, it was almost instantly rejected with double the quantity of liquid feculent matter. The abdomen was enormously distended; the hiccough very frequent; and the state of the pulse indicated the case as being nearly hopeless. Under these circumstances I suggested to Mr. Dovaston the propriety of affording the patient a chance for her life by making an artificial anus in the loin. The nature of the operation was fairly explained to her, with no concealment of the great uncertainty of its success. It was offered as a last resource, and freely accepted.

On carefully percussing the abdomen, I found that it yielded a clear tympanitic sound over its whole surface, except on the right inguinal and iliac regions. Here the sound was dull. When comparing the two sides of the belly, the right was evidently fuller and more distended than the left; and this difference was more apparent in the right lumbar region than the left.

The preparations for the operation being completed, the patient was made to lie on her belly, a firm cushion being placed underneath it. I made a free incision through the integument midway between the last rib and the crest of the ilium, commencing close to the spine, and terminating it in a line forwards with the anterior-superior spinous process of the ilium. I next divided the sacro-lumbalis and longissimus dorsi muscle, and part of the fibres of the quadratus lumborum. A quantity of fat and loose cellular tissue then presented, through which I carefully worked my way with the fore-finger and handle of the scalpel. This loose cellular and adipose tissue surrounds the kidney and intervenes between it and the peritoneal covering of the large intestine. By working downwards in the direction of the transverse processes of the spine, I kept clear of the peritoneum; and at a great depth in the wound I felt the right lumbar colon very tense, and offering a firm resistance to the pressure of the finger.

Before venturing to make an incision into the intestine, I was desirous of securing it by means of ligatures, and this part of the operation I found to be most difficult, in consequence of the great depth of the wound, and the want of needles with an acute angle. I however at length succeeded in transfixing the coats of the colon with two needles armed with a double ligature, and I then made a free incision into the intestine in a vertical direction. Out rushed a quantity of flatus and liquid fæces. In a few minutes we collected two large basinfuls of the latter, mixed with a considerable quantity of scybalæ. Although the inverted peristaltic action had gone on for so many days previous to the performance of the operation, and the vomiting had continued with scarcely any intermission, the presence of castor oil (large and repeated doses of which the patient had taken) was quite evident in the discharge through the artificial opening.

The relief experienced by the patient was most decided and immediate. In the course of a quarter of an hour the tension of the abdomen had much diminished; the hiccough ceased; and after several pints of feculent matter had been evacuated, the discharge gradually abated. I then draw the intestine more forward with the ligatures, and having passed the needles deep in the lips of the external wound, I secured the opening in the colon in a manner most favourable to admit the free escape of its contents. A large poultice of linseed meal was applied to the external wound, and the patient was placed in bed, and ordered to lie on her right side. She became faint and exhausted; but after taking a little brandy and water the pulse rallied.

Tuesday, 12th. On visiting the patient I was gratified to find the progress of the case as satisfactory as possible. Since Sunday evening there has been no vomiting, hiccough, or pain in the abdomen. The discharge through the artificial anus has been most abundant, and the tension of the abdomen has nearly subsided. There is no tenderness on pressure, and the pulse, though small and feeble, beats no more than 90. An enema was administered this morning, and brought away two very small scybala, which were coated with a putty-like substance. The patient complains of very great soreness in the wound, the edges of which are much inflamed, and the bottom shows a disposition to slough.

Ordered good beef-tea; the poultice to be changed frequently, and a large enema to be given night and morning.

Friday, 15th. I again visited the patient. She has had no unfavourable symptom until this morning, when a return of the vomiting occurred, and there is considerable tenderness over the whole right side of the abdomen. Pulse 86, rather jerking. Tongue much furred. I ascertain that since Wednesday evening the discharge through the artificial anus has been very scanty, and not a particle of feculent matter returned with the enemas, which have been regularly administered every night and morning.

On examining the wound found the ligature quite firm. There was a thick slough, like a piece of moistened brown paper, filling up the bottom of the wound. This I pressed on one side, and gave exit to a considerable quantity of fæces.

Ordered thirty leeches to be applied to the abdomen, and two grains of calomel with a quarter of a grain of opium to be given every three hours.

Wednesday, 20th. The progress of the case since last Friday has been most propitious. The tenderness of the abdomen soon subsided. The discharge through the artificial anus has been copious, but not the slightest particle of feculent matter has returned with the enemas. On examining the wound I found that the slough had separated, leaving a clear granulating surface at the sides. The ligatures were becoming loose; but as they did not appear to produce much irritation they were allowed to remain. The calomel and opium had been discontinued by the direction of Mr. Dovaston, and the only medicine taken since Monday was a small quantity of castor oil. Pulse 80. Tongue quite clear.

I did not visit Mrs. Gough again until Tuesday, 2nd November, when I found her sitting up and most grateful for her recovery. The ligatures had separated on the fifteenth day after the operation, and the whole length of the incision, excepting the part corresponding with the opening into the colon, was cicatrized. By the advice of Mr. Dovaston, the use of enemas had been persisted in night and morning; but they failed in bringing away even the smallest portion of fæces; and the patient told me she was convinced that no flatus had passed downwards since the operation had been performed. She had taken a dose of castor oil every other morning since my last visit, which produced a copious evacuation through the artificial anus.

I provided the patient with a short tube of elastic gum, which I directed her to wear in the artificial anus, and to remove whenever she feels an inclination to evacuate the bowels.

In six weeks from the day of the operation the patient walked the distance of a mile, and declared herself better in health than for many years past.

The most remarkable part of the history of this case remains to be told. At the end of six weeks from the performance of the operation, the discharge of fæces began gradually to decrease, although the patient continued taking castor oil. She was troubled greatly with flatulence, and occasionally with sharp lancinating pains through her abdomen. At the end of seven weeks the vomiting returned, accom

panied with severe colicky pains. For two days there had been scarcely any discharge through the artificial anus, and that was of a very liquid kind. The patient declared her belief that there was some obstruction at the bottom of the opening. A messenger was dispatched for Mr. Dovaston; but before his arrival at the patient's house, she had experienced a sudden and effectual relief. A hard substance had shot out from the artificial anus, which, on examination, was found to consist of five plum stones firmly agglutinated to each other. These were followed by sixteen other single plum stones, and afterwards by a very copious feculent evacuation. On the following day three more stones found an exit, accompanied with two small bones, belonging, as I should conjecture, to the pinion of a duck.

Nine months after the operation, the patient, with the exception of the local inconvenience, has no interruption to perfect health. Every week she takes castor oil, which expels one or two plum stones. The number now collected amounts to eighty-six. She has given up the use of the enemas for some weeks, as they failed to produce any good effect; and she is confident that not even flatus has passed the rectum since the operation was performed.

The progress of the case, until within six weeks of the patient's death, presented no feature of particular interest or importance. At irregular intervals, other plum stones were discharged; and the total number collected was one hundred and sixteen. By taking simple aperient pills, and an occasional dose of castor oil, the discharge through the artificial anus was free, and scarcely emitted any feculent odour. This circumstance went very far to reconcile the patient, and made her condition less loathsome and repugnant to feelings of female delicacy. The elastic tube had not been worn during the last year of the patient's life, the artificial anus being perfectly patent, and having no disposition to contract.

Within three months of her death, the patient was in the enjoyment of tolerable health. She could daily walk a considerable distance, and attend to her usual domestic affairs. The last time I saw her in Shrewsbury was in July, 1844, when she complained of loss of appetite and general debility. She had become much thinner, suffered greatly from flatulence, and required more frequent doses of aperient medicine. I had no opportunity of visiting her until nine days before her death, when I found her in a sinking state. She had then kept her bed about a fortnight; had taken but little sustenance; had no evacuation for many days, and at first obstinately refused all medicine. She was at length prevailed upon to take a few doses of an aperient mixture, which acted freely, and the discharge through the artificial anus occurred daily up to the 14th of October, when the patient died, having lived three years from the time the operation was performed.

The body was examined the day after death. Externally there was nothing worthy of observation but the extremely firm state of the cicatrix of the wound. The opening of the artificial anus was plugged up with feculent matter. The abdomen was slightly distended, and the whole body much emaciated.

On opening the abdominal cavity, the omentum was found remarkably thin, almost all trace of adipose substance being removed, leaving only a thin semi-transparent membrane. The cæcum and ascending colon were enormously distended.

I commenced tracing the intestinal canal from the duodenum to the cæcum, passing inch by inch through my fingers. The whole line was perfectly empty. There was no trace of disease or even adhesions until arriving at the termination of the ilium, where three membranous bands were discovered running in a lateral direction, and connecting that portion of the small intestines with the cæcum and ascending colon.

The cæcum itself and the ascending part of the arch of the colon appeared of unusual size, until it was suddenly cut short at the transverse part of the arch, by the intervention of the most rigid stricture I ever felt. If a piece of whip-cord had been firmly tied round this part of the intestine, the occlusion would not have been more complete than was effected by this organic change. The whole remaining portion of the transverse arch of the colon, its descending part, and the sigmoid flexure, were collapsed, and formed a thin flaccid tube.

The absence of all traces of inflammatory action in the peritoneum was very remarkable. There was no thickening, no adhesions (with the exception of the three membranous bands alluded to), or deposition of lymph. On making an incision into the intestine, between the strictured part and the caput coli, the muscular coat pre

sented the appearance of the columnæ carnea of the heart, throughout the whole length of the cæcum and colon up to the stricture, being very firm and fleshy. This appearance of the inner surface of the colon anterior to the stricture was like what is seen in the thickened condition of the bladder in cases of obstinate and long continued stricture of the urethra.

The stricture itself was of cartilaginous hardness, and the closing of the canal so complete that it would not admit the passage of even a bristle. The extent of the stricture was not quite a quarter of an inch, of a white, pearly appearance, perfectly smooth, and having no more apparent vascularity than a tendon.

The peritoneal lining of the abdomen was quite perfect, and I was surprised to find so little thickening in the neighbourhood of the part where the artificial anus was established. The opening forming the artificial anus was in the posterior part of the intestine, about an inch above the valve. The length of the opening was barely one inch. Considerable deposition of lymph was found around the posterior part of the intestine, by which it was rendered firmly adherent to the deepest part of the cicatrix of the external wound The meso-colon or duplicature of the peritoneum covering the intestine in this situation must have been separated by the great distension of the bowel, so as to allow me to open it posteriorly, without a breach of the peritoneum itself. The other abdominal viscera were healthy. No examination of the head or chest was allowed.

I believe this operation was first performed in England according to the directions of Mons. Amussat. Mr. Teale, of Leeds, performed the second; and the late Mr. Jukes, of Birmingham, the third. The detail of Mr. Jukes' case is worthy of careful perusal; and the one which I have now related proves beyond doubt the practicability of opening the ascending colon, without a breach of the investing peritoneal lining of the abdomen.

M. Amussat, to whom we are indebted for the revival of this operation, discusses, in a paper read before the Royal Academy of Medicine in Paris, the anatomical relations of the lumbar regions, and their connections with the corresponding portions of the colon. Speaking of the left colon, he says-" We find, upon attentive examination, that the intestine is destitute of peritoneum in at least its posterior third, being here surrounded by a cellular coating, continuous with that which lies upon the outer surface of the serous membrane. The three bands of longitudinal fibres may, in the lumbar colons, be described as anterior, internal, and external; and, by measuring the space between the two latter fasciculi, we may ascertain the dimensions of the part uncovered by peritoneum, since they point out the lines at which this membrane is reflected from the bowel upon the walls of the belly."

With regard to the right colon, M. Amussat reports that he has never yet found a lumbar meso-colon, although, when the intestine was contracted, the interval between the two folds of the peritoneum has been sometimes very small. At the same time he observes, that whilst the ascending colon acquires from this arrangement a greater degree of mobility than the descending, he has never yet found it possessed of a mesentery so perfect as to render it floative in the abdominal cavity. Admitting, therefore, that this objection may be urged against an attempt to perfo rate the right colon when empty, it will not necessarily constitute a sound argument against such an operation when the bowel is distended.

Although we have in many instances seen the peritoneal cavity freely laid open for the removal of large ovarian tumours with no dangerous results, I apprehend that in the performance of this operation for artificial anus, it is of the greatest importance to avoid a breach of the investing serous membrane. The wound is of necessity very deep, and in a part where sloughing, to some extent, is almost sure to take place, and any infiltration of feculent fluid within the abdominal cavity would cause inflammation and fatal consequences.

In performing the operation, I should always advise two ligatures to be passed through the coats of the intestine, leaving a sufficient space between them for a free vertical incision. With the two ligatures the intestine should be drawn upwards, as close as possible to the lips of the external wound, before the knife is plunged into the bowel.

[In the Second Case, the artificial anus was made in the descending colon. The patient was a stout and muscular man, aged 43. The symptoms were somewhat