Reports of Societies
BMJ (Clinical Research Edition)
President, in the Chair. MR. CHRISTOPHER HEATH narrated five cases of Imperforate Anus upon which he had been called to operate within the last two years. The first and fourth (both males) were examples of an anal cul-de-sac with termination of the rectum about an inch from the surface. In both cases the bowel was reached, in the first being drawn down and stitched to the margin; but both children sank, and in the last case the peritoneum was found to have been opened. The second case was the
... cond case was the male child of a medical man; there was no anus, but merely a dimple in the skin. Mr. Heath reached the bowel after cutting through some very dense structure, but was unable to draw it down to the skin. The child has thriven, and is now two years old. It has a bougie passed occasionally, and there is no great tendency to contraction. The third case was in a female child, 13 months old when brought to Mr. Heath in i868. There was no anus, but a small opening into the vagina, through which faeces escaped with difficulty and in small quantity. An attempt had been made to establish an anus in the proper situation soon after birth, but without any good result. Mr. Heath repeated the attempt, but, failing to give relief to the distension of the abdomen, afterwards divided the perinaeum, and opened freely into the rectum from the vagina. The child recovered its health, and did well until last month, when it died somewhat suddenly with symptoms of enteritis.-Mr. WILLETT had operated on several cases. In one, he passed a trocar without difficulty in a child a week old; but it died the same evening. In a girl thirteen years old, he had made a minute opening in the vagina, and stitched the bowel to the integument. He would in future, however, make deep cuts, and not put the stitches through the integument only, as in this case the sutures cut their way through. This patient wore a bougie at night, and required a laminaria tent to be passed occasionally. Mr. Willett mentioned another case which had just proved fatal under his care.-Mr. T. SMITH always recommended a tube to be passed every night. He had seen a class of cases in which there was a ring between the bowel and the anus, which could be forced by the finger, but, unless attended to, soon contracted. The bowel might be brought down and stitched; but these cases did not do well. He had for the last few years, in children with no anus, but a recto-vaginal fistula, freely laid open the perinaeum. Great relief had followed in these cases.-Mr. CALLENDER remarked that bleeding had occurred several times in his experience, and in one case with a fatal result. Another difficulty he had found was getting rid of the faeces in the lower bowel. There is always, in cases of imperforate anus, deficiency of the levator ani muscle, and loss of the muscular power of the rectum.-Mr. PAGET said that the failures were more numerous than the successes. He had under his care a patient upon whom he had operated fourteen years ago. There was an openiDg by the vagina at birth. He had made an artificial opening where the anus should have been, and had kept it patent ever since. There was no passage through the vagina, unless when the fieces were fluid. He asked whether a patient with inmperforate anus, who had been operated on, had ever lived to the age of thirty. He referred to the case of a female who for seventeen years bad an opening between the vagina and rectum; but the collection in the gut became enormous. The rectum in these cases forms a large pouch, communicating by a very small opening with the colon; and it was so in this case. He dilated the opening, and scooped out masses of very hard faeces and crystallised triple phosphate. It finally emptied itself, and now the patient passes the faeces through the vaginal opening. He had treated ten to fifteen cases, and these were the only two cases which hadproved so far successful. Dr. DUCKWORTH communicated a case of the True Keloid of Alibert -which had been under his observation for two years. It was illustrated by a coloured plaster cast and a water-colour sketch. The points of interest in the case were that it occurred in a male, aged 65, and had been growing slowly for thirty-six years; that it occupied the sternal region, a locality affected in nearly half of the recorded cases; and that no cause of any kind was assigned as a starting-point for the disease. The case agreed remarkably with several that had been carefully observed and described, and Dr. Duckworth expressed his belief that we were in possession of sufficient facts to warrant the distinction of these cases, originally made by Alibert, into true or spontaneous, and false or cicatricial, keloid. Mr. Hutchinson had lately asserted, in the BRITISH MEDICAL JOURNAL, that Alibert's keloid was a disease of scars and not of skin, and that the affection was scarcely ever met with in adults or in elderly persons, excepting with a short history, and that after reaching a climax of growth it commenced to soften and lose its irritability. This case appeared to disprove these statements, since it afforded the longest history of true keloid yet recorded, and the growth continued to enlarge and cause, perhaps, more pain and discomfort each year. Mr. Hutchinson's observations seemed solely to apply to the spurious or cicatricial form of the disease.-Dr. Duckworth stated, in answer to Mr. Richard Davy, that several microscopical examinations of these cases had been made; and the disease was found to consist ofwavy fibrous tissue with spindle-shaped cells, and numerous large bundles of nerves. Dr. HANDFIELD JONES related a case of Fatal Epileptic Stupor occurring in a young woman who had been admitted into St. Mary's Hospital in a state of unconsciousness. In the absence of any history, diagnosis was at first difficult. She had bed-sores; no decided paralysis ; increased temperature; quiet respiration; no spots; the urine was not albuminous, and was deficient in uric acid. She died in asthenia twenty-five days after admission, and the autopsy showed chiefly an atrophied brain with much arachnoid and ventricular fluid. Three relatives -had died insane or epileptic; she had suffered from epilepsy and from mania lasting one month, and a fit had occurred two months prior to the last seizure. It was considered that the encephalon was either originally imperfectly developed or had undergone atrophic change, and that the fluid in the arachnoid and ventricles was complementary. The stupor was probably consecutive to an epileptic paroxysm.-Dr. LEARED brought forward the case of a gentleman who was seized with epileptoid fits after an attack of apoplexy. The fits were so protracted that apparent death from apnoea ensued on six occasions, and the patient was restored to animation each time by Silvester's method of artificial respiration. The duration of apnoea after a fit was on one occasion two minutes and a half, and the length of the fit itself was certainly not less, during which, also, respiration was in complete abeyance from spasm of the glottis. There was therefore a period of complete apnoea of five minutes. By the aid of bleeding from the arm and the subcutaneous injection of bromide of potassium, he improved so much that he survived five days, during which he was at times able to converse rationally with members of his family. He died at length from asthenia. As a last resource ammonia was injected into a vein, but with no good result.-Dr. JONES, in reply to Dr. Powell, stated that the temperature was 102 to 103 deg., but that there was not any other evidence of inflammation.-Dr. BEIGEL asked if a patient, because he died in convulsions, died of epilepsy. He did not think the case of Dr. Jones was one of epilepsy. He considered that there was enough to account for the convulsions. These were not, he considered, cases of epilepsy. -Dr. JONES thought his case was one of cerebral hremorrhage.-Dr. BUZZARD had seen the case. The interest was in the difficulty of diagnosis. He had difficulty in recognising the benefit of artificial respiration in cases of cerebral effusion of blood. The asphyxia was perhaps caused by spasm of the laryngeal muscles from cerebral irritation; and, the venous blood being got rid of by artificial respiration, a further effusion of blood perhaps took place after this. The bromide of potassium, used subcutaneously, was a valuable means of treating patients when unable to swallow. MEDICAL SOCIETY OF LONDON. MONDAY, MARCH 14TH, I870. JOHN GAY, Esq., President, in the Chair. MR. CLENMENT GODSON exhibited a very convenient Obstetric Bag made by Arnold of Smithfield. It carried all the necessary instruments for every kind of obstetric operation, conveniently packed in small compass in each side, while in the centre were cases for bottles to hold ammonia, brandy, etc. Mr. HENRY SMITH exhibited the Head of a Femur, given to him by Mr. Price of Margate, from a case of strumous disease of the hipjoint, with abscess, in a lad of I5. -The head of the bone came away in one of the poultices, the patient making a good recovery, with fair movement in the limb. Dr. GREENHALGH showed a long Funis, on which were found two knots. The child was a small one, but living.-Mr. PETER MARSHALL had met with a similar case.-Dr. RICHARDSON and Mr. JABEZ HOGG thought that the knots were formed during birth.-Dr. ROUTH mentioned instances of amputation of limbs in utero by their becoming tied in the funis.