ST. THOMAS'S HOSPITAL
Nulla autem est alia pro certo noscendi via, nisi quamplurimas at morborum et dissectionum historias, tum aliorum tum proprias collectas habere, et inter se compa.ra.re.—MoB&ASNl De 5ed. et Caus. Morb. lib. iv. Frocemium. -W. K---, aged fifty-four, married, was admitted under the care of Mr. Sydney Jones on May 15th, 1884, and died on the 26th. The family history was good, and there was no record of tumour. She married twenty-nine years ago, and had had seven children, the youngest of whom is
... ungest of whom is aged sixteen. Four died from measles or scarlet fever; the others are living and healthy. She had had no miscarriages. She has suffered from herniae since the birth of her first child (right inguinal and femoral) ; for these she had worn a truss, but only for two months. Six months ago she felt pain in the right side of the abdomen; this pain was worse during and after exercise, and she knew of no cause for it. Four months ago she noticed a swelling in the part of the abdomen where she felt pain; it increased in size, but has not changed in position. The pain has been worse after a hearty meal and during exercise, but she did not think that she had lost flesh, and her appetite continued good. She had always suffered from constipation, but since Christmas the bowels had been more than ever confined, and her motions had been of a dark almost black colour recently, but she did not know that she had ever passed blood. The catamenia ceased about seven years ago ; until then she was quite regular. On admission she was a thin pale woman with an anxious expression, complaining of a swelling in the abdomen. On the right side of the abdomen about the level of the anterior superior spine was a solid tumour, about two inches and a half in diameter, of very irregular outline. It appeared to be attached to the abdominal wall, did not move with respiration, but was not fixed; it could be moved from side to side. It was tender to the touch, firm and hard, and somewhat irregular on the surface. The resonance of the abdomen generally was good, but was modified over the tumour; there was not absolute dulness. The abdominal walls were lax, and there was a hernia in both the inguinal and femoral regions on the right side, the former easily descending when the patient stood, and being easily reduced with gurgling ; the latter small, descending less easily. The organs generally were healthy. Urine 1027, no albumen, contained a little mucus. The patient suffered a great deal of pain and was anxious for something to be done to relieve her. -May 23rd.-The patient having been prepared for the operation in the usual manner, and the bowel cleared by an enema, she was put under the influence of ether, and Mr. Sydney Jones performed the following operation. An incision four to five inches in length was made from above downwards over the centre of the tumour, and when the abdominal walls had been divided and bleeding points ligatured, the carbolic spray was turned on, and the remainder of the operation completed under it. The tumour was found flattened and adherent to the peritoneum, and there was slight bleeding when it was separated; it was found to be situated in the upper part of the ascending and part of the transverse colon. A warm sponge was placed over the exposed intestines whilst the diseased portion was examined. It was decided to excise the csecum and all that part of the intestine which was involved. The mesentery and omentum were ligatured by silk ligatures piece by piece, and then divided. A clamp covered with indiarubber was put on the intestine on each side of the line of proposed separation, and the intestine was then divided by scissors, and any bleeding points twisted with forceps. A small piece of sponge was inserted into the open end of the ileum whilst the tumour was being dissected out. The tumour and involved intestine were removed from the transverse colon in a similar manner. It was decided to bring the two ends together without making an artificial anus. About fourteen fine silk sutures were passed through the whole thickness of the intestine, so that the two cut ends were united around their whole circumference ; others were passed through the serous coat alone, and one was passed (near the wound) so as to attach the serous coat to the abdominal wall. After the clamps had been removed there was a little ecchymosis and congestion of the gut near the place where they had been applied. The abdominal cavity was then carefully wiped out with dry warm sponges, and three sutures were passed through the upper part of the edges of the wound and one through the lower; the middle part of the wound was left open, and a light plug of iodoform gauze was inserted into it. The wound was dressed antiseptically, a bag of sublimated wood wool being used to soak up any discharge, and this was bandaged on with carbolic gauze bandages. The pulse was good after the operation. A half-grain suppository of morphia was given before the patient was put back to bed. 24th.-She complained of pain occasionally during the night and did not sleep for more than half an hour at a time, although injections of morphia were administered at seven and eleven last evening. The urine was drawn off everyeight hours. Temperature last night 98'4°; this morning 100°. She had another injection of morphia in the early morning and suffered no pain during the early part of the , day. Pulse 134, bounding and easily compressible; respiration easy (25); tongue dry; has taken ice only; urine 1030, acid, a deposit of lithates, no albumen, some mucus. 2 P.M.: Temperature 101 '20, patient quiet and without pain. 8 P.M.: Temperature 104'4° ; restlessness, no pain. The wound was dressed on account of the rise of temperature ; the plug was found covered with quite sweet coagulum; the dressmg gave no , pain; the spray was used. The wound looked well and i there was no abdominal distension. An injection of one-i third of a grain of morphia was given, after which she slept for two hours. 25th.-The patient seemed better, no pain; pulse 124 at , noon, and occasionally intermittent; temperature, 2 A.M.,. 1038°, 8 A.M., 103-60, 2 P.M., 103°, 8 P.M., 1026°. i 26th.-She slept about two hours during the night after' , the injection of one-third of a grain of morphia. She ' became weaker towards the morning, and her temperature , rose to 1044° at 2 A.M. She was worse at 8 A.M., when the I temperature was 104°, and a teaspoonful of brandy was , ordered to be given every hour. 11 A.M. : She was sinking ; i the pulse could hardly be felt, temperature 1044° An . injection of ether and a nutrient enema were given, i after which she revived a little but sank, dying quietly i at 1.45 P.M. ! At the post-mortem examination, made on the following day by Dr. Sharkey, the abdominal cavity contained no . fluid, and there was no general peritonitis. The site of the operation was the right iliac and lumbar region, where the small intestine had evidently been united to the large after , a portion of the bowel had been removed. The line of junction was very vascular, but there was no inflammation ) except at the point where the mesentery was attached; here dirty-looking pus had infiltrated the tissues. Water ; injected through the gut passed freely and easily by the seat of the operation; but on putting a little more . pressure a larger, but still moderate, stream of water . trickled through the wall of the gut at the junction of the mesentery with it. This slight oozing was probably the i cause of the local inflammation. There was a moderate , degree of atheroma of the valves on the left side of the . heart ; the lungs were both greatly congested and oedematous in dependent parts; the kidneys were rather small, and L their capsules very slightly adherent; otherwise the organs were healthy. . Remarks.—Having little doubt as to the nature and seat of the growth, and taking into consideration the inevitable , ending if no operation were performed, either from local ) extension and involvement of surrounding parts or possibly obstruction of the bowel from diminished calibre of the gutthe patient suffering much pain from the growth, which was . increasing somewhat rapidly in size, and being anxious for ; relief-Mr. Sydney Jones performed the operation described . above; and the general and local condition (there being no 3 enlargement of the neighbouring glands nor visceral disease, L as proved post mortem) justified the expectation of a successful result.