THE INDIAN MEDICAL GAZETTE.
254
A MIRROR OF HOSPITAL PRACTICE. SOME CASES OF ABDOMINAL TUMOUR. By Sukgeon M. D. Moriabtt, M. B.,
Civil-Surgeon, Sultanpore, The following cases were treated at the course of last year.
I.?Hydatid disease of B.,
a
Chamar. age 25 years,
was
Ondh.
Muzuffarnagar during
the
kidney.
admitted into the dispen*
sary on 20th May 1880. The patient on admission was very ill, and could give no connected account of his troubles ; it was gathered that he had been ill for some four years ; was worse for the last four months, and was very bad for the last few days. All his troubles appeared to be centred in a lump in his belly. He had much fever, and was slightly delirious ; tongue dry and brown ; pulse very rapid ; the abdomen was much swollen, measuring a little above the umbilicus 37| inches ; it was very tender ; he could only lie on the right side ; the swelling was found to occupy chiefly the right side of the abdomen ; it presented three distinct rounded lumps, the largest, about the size of a foetal head, lay above and to the right of the umbilicus, the next was above and outside this in the right hypochondrium, while the third and smallest occupied the right iliac region ; these lumps all felt liquid, especially the larger one, a tap on almost any part of the belly sent a thrill through the whole tumour, but most marked in the large lump ; the swelling extended back wards into the right iumbar region, and to the right of the large lump felt solid ; the left margin of the tumour could not be clearly made out by palpation, the only parts of the abdomen where percussion gave a clear note were the upper part of the epigastrium, the left hypochondrium, the left lumbar region, and so down along the sigmoid flexure and rectum. The diagnosis was hydatid tumour, inflamed, if not suppurating ; a small trocar was plunged into the lower and right side of the larger mass and 272 ounces of a dark brown turbid fluid drawn off ; the fluid ran freely, when it began to fail the canula was removed ; on resting the fluid developed an oily sort of scum. Examined under the microscope it was found to contain innumerable pus cells, some large inflammatory corpuscles, scveral'crystals, which at first sight looked like oxalate of lime, but which subsequent examination convinced me were triple phosphates, some pear-shaped granular bodies ; one object which looked like a hooklet of the echinococcus was seen, I could not however satisfy myself of the identity of this, nor did I find another like it; the fluid was not examined chemically ; the belly a little above the umbilicus now measured 21 \ inches. A firm binder was
applied.
Next day the patient was much better ; there was still considerable tenderness over the right side of the belly. The liver and spleen were now distinctly made out, both slightly enlarged downwards (doubtless the removal of the pressure caused them to come down a bit.) The right lumbar region as compared to the left felt full. On percussion almost all the right half of the abdomen, right up to the liver, was dull ; no clear note separated this dulness from that of the liver ; the idea conveyed was that the part was occupied by a large all which of adhesions round preventempty cyst by reason ed the intestines from returning to their normal situations. On 22nd the patient was still better, fever rapidly subsiding, tongue moist and cleaning, abdominal tenderness much less, the dulness apparently diminishing, i. e. contracting. The urine was found to be light colored and slightly acid ; on resting, a considerable puriform sediment formed. Under the microscope this sediment was found to contain pus cells, larger granular cells (mucous corpuscles ?), large granular ?
inflammatory corpuscles, granular matter, granular squamous cells, and crystals of triple phosphate, many of these latter
small, and very little octahedra of oxalate of lime. Even at this stage it was impossible to get a clear history from the patient; leading questions such as, did he ever pass large quantities of urine suddenly, were answered as he thought pleased me most. He did well for some days. On 8th June, he was found to have inflammation of the left femoral vein. The belly was also 1 arger, measuring 30J inches. He was feverish j fluctuation was were
[September 1,
1881.
detected in the tumour ; the dulness was still continuous with that of the liver, though in the axillary line the tumour distinctly fell away from the liver, giving the idea of a deep attachment. The urine was as before, the crystals perhaps fewer ; I noticed in it (under the microscope) one or two what appeared to be shreds of membrane, but I could not accurately make out their structure ; they were very small. The phlebitis was treated in the usual way, and on 19th June had disappeared, leaving only a little thickening to mark its site ; the belly however had increased to 32? inches, and there was considerable fever. I tapped him in the right flank a little anterior to the axillary line, and removed about 100 ounces of a whitish puriform fluid, in examining which under the microscope nothing but pus cells and a few triple
again
phosphate crystals were seen. Marked improvement followed ; the fever diminished, the urine became almost quite clear* and was passed freely? apparently it was somewhat diminished before the tapping, but no accurate measurements were made, as the patient was difficult to manage. At no time had he pain on micturition. As he lay on his back the right lumbar region felt full, but when he lay over on his left side it felt hollow and empty, the liver was manifestly enlarged downwards, but no distinct connection, beyond the continuity of dulness, could be made out between it and the tumour, which appeared to lie below it. The patient absconded on 26th June, and was never more seen.
Remarks.?At first sight the tumour appeared to be an inflamed hydatid, and, notwithstanding its great extension downwards, was thought to be connected with the liver, this of all abdominal organs being known to be the most common seat of a disease. After the tapping it became pretty evident that the liver, though enlarged, was not the seat of the disease, its free margin and part of its anterior surface could be distinctly felt, and no unevenness could be discovered ; the tumour now appeared to be renal ; that it was such I have little doubt, the nature of the urinary deposit went to show that either the kidney suffered from the pressure of the tumour, i. e. that there was some pyelitis, or that a communication existed between the tumour and some part of the urinary tract; the latter is I think, from the history of the case,
unlikely.
The diagnosis lay between cystic degeneration and hydatid disease ; on the whole I think the disease was most signs were absent, probably hydatid ; true the no secondary cysts were seen, and booklets were not satiscysts without any seconfactorily made out. Single dary cysts, though rare, are met with ; had a chemical examithe of urine been made it nation of the fluid and also probably would have helped to clear up the diagnosis. The man's caste was also in favor of hydatid disease,?chamars are which a more filthy feeder very partial to the village pig, than can scarce be conceived. The three lumps originally observed evidently communicated with one another, or were three separate expansions one caused the of the same tumour, for the tappin? collapse of all three.
pathognomonic hydatid
II.?Suppurating Hydatid of
the liver.
Mahotnedan woman, age 25 years, was admitted into hospital on 3rd August 1880. Patient was the mother of three children, the youngest of which, born about a year ago, had died at the age of six months. Menstruation was regular, a period being now due. The patient stated that for the last three years she had been conscious of a small lump in her right side just below the ribs, that twenty-seven days ago this lump, without any reason, began to enlarge, and has since gone on steadily enlarging, the enlargement being attended with pain, fever, dyspnoea, and loss of appetite. The woman looked very ill and weak, she had considerable fever, no jaundice. In the upper and right part of the abdomen was a large rounded swelling, extending upwards to the margin of the ribs, across the epigastrium to the left hypochondrium and downwards to about 3 inches below and to the left of the umbilicus, it did not extend into the right lumbar N.
a
region.
The tumour was very tense, dull on percussion, and gave on tapping a very doubtful thrill; it was distinctly fluid,especially that part of it to the right and a little above the umbilicus?
percussion revealed
no
intestine between the tumour and the
September 1,
1881.]
A MIRROR OF HOSPITAL PRACTICE.
255
the treatment. The acute dysentery which supervened on liver ; the dulness of both was continuous ; the liver dulas third day, might just as well hare followed incision as usual ; the skin over the ness did not extend as high up be said of the pneumonia tumour appeared to be quite natural ; tenderness was not tapping, and the same may of pus after as to whether the tumour was which ended the case. The discharge very marked. I have no note the first tapping was never profuse ; on the contrary affected by respiration. it was surprisingly small, there was never the least sign of The largest needle of an aspirator was introduced into the the symptoms were undoubtedly most fluid part of the tumour, about 2f" above and to the putrefaction in the sac, yet the dysentery and diarrhoea conWere close of well a hectic make of the as I and as could out, type. umbilicus, right nected with the loss of bile ? "What the motions were like by the outer border of the rectus muscle ; a little green before she came to hospital I don't know, yet I certainly pus came into the bottle and the needle became plugged ; think the escape of bile had some connection with the bowel removing it, I introduced a medium sized trocar, the canula affection. At the same time, when the bile again began to of this likewise became plugged ; I then introduced the flow through its normal channels, the bowels did not improve largest trocar I had, through the canula of this thin greenish due to another cyst yellow and slightly odorous pus, with innumerable bladders of as I had hoped. Was the pneumonia towards the lung 7 It may various sizes, slowly but steadily flowed, the canula frequently making its way, i. e. growing more have been so but in such case one would expect became plugged, but with a long silver probe I was always and pleural irritation. marked signs of able to clear it; by a little lateral pressure the obstructing bladder was always got out; the flow went on for nearly two HI Cancer of the Gall bladder and gastro-hepatic omentum. hours, towards the end a little bile occasionally appeared, it was quite separate from the pus, and after a drachm or so i Mahnmpdan. age 35 years, was admitted into the of it came it ceased abruptly and was followed by pure pus. 1880. The patient stated that lie dispensary on 28th June At the end a very thick, curdy, and almost inspissated pus had been ill for nine months, and attributed all his sufferings, came away. Some air now entered the sac ; the flow having which were great, to a painful lump in the right side of his On examination, he was seen to be ceased, I injected a one per cent carbolic solution four times, belly just below the ribs. till in fact it returned almost quite clear ; introducing a piece much emaciated, his face had a dreadfully haggard look ; of drainage tube about the thickness of a goose quill through his feet were slightly oedematous: he was deeply the canula, I withdrew the latter ; the tube was kept in posihe said he had never vomited, and never had black stools. round tion by a string passed through its free end and tied Immediately beneath the right ribs in front a tumour could the body. Towards the end of the operation a slight flush be seen as well as felt; the lung was very uneven and of stony the to round when the canula ; began appear on the skin hardness it moved with respiration, no friction could be cavity was entirely emptied this became deeper and more the diagnosis was of course cancer, probably of the bewas seized and the when extensive, part pretty firmly liver. The treatment was directed to little else than to induce tween the fingers and thumb it became evident that the euthanasia ; his end was plainly very near ; a liberal supply cyst in this situation was adherent to the abdominal wall; of days a little less miserable opium made his few remaining inability to satisfy myself of this at first caused me to tap than they otherwise would have been ; he died in collapse rather than incise. The operation was followed by great on the 10th July. relief, the fever almost and the pain altogether disapAt the autopsy the tissues were found to be universally peared ; the tongue became clean; almost pure bile and bile-stained ; there was a little yellow serum in discharged through the tube. On the evening of the the deeply cavity; the liver was hard and of a dark green peritoneal 5th purging came on, and by next morning had deve- color; the gall bladder was enormously distended, and bulged into loped pure dysentery. Under treatment the acute some inches into the substance of the right lobe, when symptoms had disappeared by_ the 8th, but the bowels it wasfour the bile shot out with great force; except punctured remained loose; the motions an almost entire at one small part near the left lobe of the liver; the gall absence of bile she was given ten grains of purified ox gall bladder was one hu^e mass of cancer, its mucous coat was not daily, this was of doubtful benefit. The cavity was washed involved it was however much thickened, and was coated out morning and evening ; bile discharged almost daily, and with a thick slime, which at one place was almost purulent , sometimes a little pus, the latter was laudable, and never and common bile ducts could not be traced ; the showed the least sign of putrefaction. Thinking that the the cystic omentum was a mass of cancer,with huge vessels bowels might improve if the loss of bile was diminished, I gastro-hepatic in it. The duodenum and hepatic flexure of the colon were removed the drainage tube and covered the opening with to the cancerous mass ; tliey could however oiled lint; the motions became yellow, but still the diar- intimately adherent there was no indication of their having be from it; separated rhoea did not cease, occasionally it became dysenteric ; the been obstructed, though no doubt their calibre was diminished; tube was re-introduced. She steadily got worse ; the mornthe pylorus was quite free of the disease; the neighbouring ing temperature was nearly always sub-normal 96-5? to 97-5?, there being numerous was infected, the evening temperature ranged from 99*5? to 100: ; the parietal peritoneum wart-like growths from it ; similar growths sprang from the was weak, and in evening usually went up to 100 or 110. serous at vaiious parts ; the great pulse covering of the bowels On the 16th the opening was re-dilated with a laminaria tent omentum was curled up, there were numerous nodules in it; and a large drainage tube introduced, this was followed by the lower bowel contained hard faecal matter. The hepatic a great flow of bile (through the tube.) On the 18th she was tissue to be quite free of cancer; the portal proper appeared drachms after each meal two of Pancreafresh given Liquor canals were dilated and thickened ; the diaphragm was much ticus, prepared according to Dr. W. Roberts' directions. No thickened, and adherent to the liver, but no nodules were marked advantage resulted from this. On the 19th symptoms of consolidation of the base of the i observed in it. Ileum into the colon .* Gangrene. right lung appeared, and advanced slowly but steadily ; she IV. Intussusception of the 35 years, was admitted into the got a troublesome cough; the diarrhoea was sometimes a Mahomedan, age Sadi, better sometimes worse ; the motions now always contained dispensary on 13th September 1880; he had been ill for twentyplenty of bile ; the tongue was clean, but small and smooth, one days; the illness began with pain in the belly and constit. e. had lost much of its epithelium. The discharge of bile pation ; some native quack gave him several powerful purgathat he was purged about 100 and pus from the tube became quite insignificant, but that tives, the result of which was his there was still a large cavity was shown by the way the times in twenty-four hours ; to pain continued and a lump act. On examination the injection passed in ; the pneumonia progressed, the posterior appeared, the bowels ceased little third of the lung became quite solid ; the morning tempera- patient was found to be feverish, pulse quickened and a w
254
A MIRROR OF HOSPITAL PRACTICE. SOME CASES OF ABDOMINAL TUMOUR. By Sukgeon M. D. Moriabtt, M. B.,
Civil-Surgeon, Sultanpore, The following cases were treated at the course of last year.
I.?Hydatid disease of B.,
a
Chamar. age 25 years,
was
Ondh.
Muzuffarnagar during
the
kidney.
admitted into the dispen*
sary on 20th May 1880. The patient on admission was very ill, and could give no connected account of his troubles ; it was gathered that he had been ill for some four years ; was worse for the last four months, and was very bad for the last few days. All his troubles appeared to be centred in a lump in his belly. He had much fever, and was slightly delirious ; tongue dry and brown ; pulse very rapid ; the abdomen was much swollen, measuring a little above the umbilicus 37| inches ; it was very tender ; he could only lie on the right side ; the swelling was found to occupy chiefly the right side of the abdomen ; it presented three distinct rounded lumps, the largest, about the size of a foetal head, lay above and to the right of the umbilicus, the next was above and outside this in the right hypochondrium, while the third and smallest occupied the right iliac region ; these lumps all felt liquid, especially the larger one, a tap on almost any part of the belly sent a thrill through the whole tumour, but most marked in the large lump ; the swelling extended back wards into the right iumbar region, and to the right of the large lump felt solid ; the left margin of the tumour could not be clearly made out by palpation, the only parts of the abdomen where percussion gave a clear note were the upper part of the epigastrium, the left hypochondrium, the left lumbar region, and so down along the sigmoid flexure and rectum. The diagnosis was hydatid tumour, inflamed, if not suppurating ; a small trocar was plunged into the lower and right side of the larger mass and 272 ounces of a dark brown turbid fluid drawn off ; the fluid ran freely, when it began to fail the canula was removed ; on resting the fluid developed an oily sort of scum. Examined under the microscope it was found to contain innumerable pus cells, some large inflammatory corpuscles, scveral'crystals, which at first sight looked like oxalate of lime, but which subsequent examination convinced me were triple phosphates, some pear-shaped granular bodies ; one object which looked like a hooklet of the echinococcus was seen, I could not however satisfy myself of the identity of this, nor did I find another like it; the fluid was not examined chemically ; the belly a little above the umbilicus now measured 21 \ inches. A firm binder was
applied.
Next day the patient was much better ; there was still considerable tenderness over the right side of the belly. The liver and spleen were now distinctly made out, both slightly enlarged downwards (doubtless the removal of the pressure caused them to come down a bit.) The right lumbar region as compared to the left felt full. On percussion almost all the right half of the abdomen, right up to the liver, was dull ; no clear note separated this dulness from that of the liver ; the idea conveyed was that the part was occupied by a large all which of adhesions round preventempty cyst by reason ed the intestines from returning to their normal situations. On 22nd the patient was still better, fever rapidly subsiding, tongue moist and cleaning, abdominal tenderness much less, the dulness apparently diminishing, i. e. contracting. The urine was found to be light colored and slightly acid ; on resting, a considerable puriform sediment formed. Under the microscope this sediment was found to contain pus cells, larger granular cells (mucous corpuscles ?), large granular ?
inflammatory corpuscles, granular matter, granular squamous cells, and crystals of triple phosphate, many of these latter
small, and very little octahedra of oxalate of lime. Even at this stage it was impossible to get a clear history from the patient; leading questions such as, did he ever pass large quantities of urine suddenly, were answered as he thought pleased me most. He did well for some days. On 8th June, he was found to have inflammation of the left femoral vein. The belly was also 1 arger, measuring 30J inches. He was feverish j fluctuation was were
[September 1,
1881.
detected in the tumour ; the dulness was still continuous with that of the liver, though in the axillary line the tumour distinctly fell away from the liver, giving the idea of a deep attachment. The urine was as before, the crystals perhaps fewer ; I noticed in it (under the microscope) one or two what appeared to be shreds of membrane, but I could not accurately make out their structure ; they were very small. The phlebitis was treated in the usual way, and on 19th June had disappeared, leaving only a little thickening to mark its site ; the belly however had increased to 32? inches, and there was considerable fever. I tapped him in the right flank a little anterior to the axillary line, and removed about 100 ounces of a whitish puriform fluid, in examining which under the microscope nothing but pus cells and a few triple
again
phosphate crystals were seen. Marked improvement followed ; the fever diminished, the urine became almost quite clear* and was passed freely? apparently it was somewhat diminished before the tapping, but no accurate measurements were made, as the patient was difficult to manage. At no time had he pain on micturition. As he lay on his back the right lumbar region felt full, but when he lay over on his left side it felt hollow and empty, the liver was manifestly enlarged downwards, but no distinct connection, beyond the continuity of dulness, could be made out between it and the tumour, which appeared to lie below it. The patient absconded on 26th June, and was never more seen.
Remarks.?At first sight the tumour appeared to be an inflamed hydatid, and, notwithstanding its great extension downwards, was thought to be connected with the liver, this of all abdominal organs being known to be the most common seat of a disease. After the tapping it became pretty evident that the liver, though enlarged, was not the seat of the disease, its free margin and part of its anterior surface could be distinctly felt, and no unevenness could be discovered ; the tumour now appeared to be renal ; that it was such I have little doubt, the nature of the urinary deposit went to show that either the kidney suffered from the pressure of the tumour, i. e. that there was some pyelitis, or that a communication existed between the tumour and some part of the urinary tract; the latter is I think, from the history of the case,
unlikely.
The diagnosis lay between cystic degeneration and hydatid disease ; on the whole I think the disease was most signs were absent, probably hydatid ; true the no secondary cysts were seen, and booklets were not satiscysts without any seconfactorily made out. Single dary cysts, though rare, are met with ; had a chemical examithe of urine been made it nation of the fluid and also probably would have helped to clear up the diagnosis. The man's caste was also in favor of hydatid disease,?chamars are which a more filthy feeder very partial to the village pig, than can scarce be conceived. The three lumps originally observed evidently communicated with one another, or were three separate expansions one caused the of the same tumour, for the tappin? collapse of all three.
pathognomonic hydatid
II.?Suppurating Hydatid of
the liver.
Mahotnedan woman, age 25 years, was admitted into hospital on 3rd August 1880. Patient was the mother of three children, the youngest of which, born about a year ago, had died at the age of six months. Menstruation was regular, a period being now due. The patient stated that for the last three years she had been conscious of a small lump in her right side just below the ribs, that twenty-seven days ago this lump, without any reason, began to enlarge, and has since gone on steadily enlarging, the enlargement being attended with pain, fever, dyspnoea, and loss of appetite. The woman looked very ill and weak, she had considerable fever, no jaundice. In the upper and right part of the abdomen was a large rounded swelling, extending upwards to the margin of the ribs, across the epigastrium to the left hypochondrium and downwards to about 3 inches below and to the left of the umbilicus, it did not extend into the right lumbar N.
a
region.
The tumour was very tense, dull on percussion, and gave on tapping a very doubtful thrill; it was distinctly fluid,especially that part of it to the right and a little above the umbilicus?
percussion revealed
no
intestine between the tumour and the
September 1,
1881.]
A MIRROR OF HOSPITAL PRACTICE.
255
the treatment. The acute dysentery which supervened on liver ; the dulness of both was continuous ; the liver dulas third day, might just as well hare followed incision as usual ; the skin over the ness did not extend as high up be said of the pneumonia tumour appeared to be quite natural ; tenderness was not tapping, and the same may of pus after as to whether the tumour was which ended the case. The discharge very marked. I have no note the first tapping was never profuse ; on the contrary affected by respiration. it was surprisingly small, there was never the least sign of The largest needle of an aspirator was introduced into the the symptoms were undoubtedly most fluid part of the tumour, about 2f" above and to the putrefaction in the sac, yet the dysentery and diarrhoea conWere close of well a hectic make of the as I and as could out, type. umbilicus, right nected with the loss of bile ? "What the motions were like by the outer border of the rectus muscle ; a little green before she came to hospital I don't know, yet I certainly pus came into the bottle and the needle became plugged ; think the escape of bile had some connection with the bowel removing it, I introduced a medium sized trocar, the canula affection. At the same time, when the bile again began to of this likewise became plugged ; I then introduced the flow through its normal channels, the bowels did not improve largest trocar I had, through the canula of this thin greenish due to another cyst yellow and slightly odorous pus, with innumerable bladders of as I had hoped. Was the pneumonia towards the lung 7 It may various sizes, slowly but steadily flowed, the canula frequently making its way, i. e. growing more have been so but in such case one would expect became plugged, but with a long silver probe I was always and pleural irritation. marked signs of able to clear it; by a little lateral pressure the obstructing bladder was always got out; the flow went on for nearly two HI Cancer of the Gall bladder and gastro-hepatic omentum. hours, towards the end a little bile occasionally appeared, it was quite separate from the pus, and after a drachm or so i Mahnmpdan. age 35 years, was admitted into the of it came it ceased abruptly and was followed by pure pus. 1880. The patient stated that lie dispensary on 28th June At the end a very thick, curdy, and almost inspissated pus had been ill for nine months, and attributed all his sufferings, came away. Some air now entered the sac ; the flow having which were great, to a painful lump in the right side of his On examination, he was seen to be ceased, I injected a one per cent carbolic solution four times, belly just below the ribs. till in fact it returned almost quite clear ; introducing a piece much emaciated, his face had a dreadfully haggard look ; of drainage tube about the thickness of a goose quill through his feet were slightly oedematous: he was deeply the canula, I withdrew the latter ; the tube was kept in posihe said he had never vomited, and never had black stools. round tion by a string passed through its free end and tied Immediately beneath the right ribs in front a tumour could the body. Towards the end of the operation a slight flush be seen as well as felt; the lung was very uneven and of stony the to round when the canula ; began appear on the skin hardness it moved with respiration, no friction could be cavity was entirely emptied this became deeper and more the diagnosis was of course cancer, probably of the bewas seized and the when extensive, part pretty firmly liver. The treatment was directed to little else than to induce tween the fingers and thumb it became evident that the euthanasia ; his end was plainly very near ; a liberal supply cyst in this situation was adherent to the abdominal wall; of days a little less miserable opium made his few remaining inability to satisfy myself of this at first caused me to tap than they otherwise would have been ; he died in collapse rather than incise. The operation was followed by great on the 10th July. relief, the fever almost and the pain altogether disapAt the autopsy the tissues were found to be universally peared ; the tongue became clean; almost pure bile and bile-stained ; there was a little yellow serum in discharged through the tube. On the evening of the the deeply cavity; the liver was hard and of a dark green peritoneal 5th purging came on, and by next morning had deve- color; the gall bladder was enormously distended, and bulged into loped pure dysentery. Under treatment the acute some inches into the substance of the right lobe, when symptoms had disappeared by_ the 8th, but the bowels it wasfour the bile shot out with great force; except punctured remained loose; the motions an almost entire at one small part near the left lobe of the liver; the gall absence of bile she was given ten grains of purified ox gall bladder was one hu^e mass of cancer, its mucous coat was not daily, this was of doubtful benefit. The cavity was washed involved it was however much thickened, and was coated out morning and evening ; bile discharged almost daily, and with a thick slime, which at one place was almost purulent , sometimes a little pus, the latter was laudable, and never and common bile ducts could not be traced ; the showed the least sign of putrefaction. Thinking that the the cystic omentum was a mass of cancer,with huge vessels bowels might improve if the loss of bile was diminished, I gastro-hepatic in it. The duodenum and hepatic flexure of the colon were removed the drainage tube and covered the opening with to the cancerous mass ; tliey could however oiled lint; the motions became yellow, but still the diar- intimately adherent there was no indication of their having be from it; separated rhoea did not cease, occasionally it became dysenteric ; the been obstructed, though no doubt their calibre was diminished; tube was re-introduced. She steadily got worse ; the mornthe pylorus was quite free of the disease; the neighbouring ing temperature was nearly always sub-normal 96-5? to 97-5?, there being numerous was infected, the evening temperature ranged from 99*5? to 100: ; the parietal peritoneum wart-like growths from it ; similar growths sprang from the was weak, and in evening usually went up to 100 or 110. serous at vaiious parts ; the great pulse covering of the bowels On the 16th the opening was re-dilated with a laminaria tent omentum was curled up, there were numerous nodules in it; and a large drainage tube introduced, this was followed by the lower bowel contained hard faecal matter. The hepatic a great flow of bile (through the tube.) On the 18th she was tissue to be quite free of cancer; the portal proper appeared drachms after each meal two of Pancreafresh given Liquor canals were dilated and thickened ; the diaphragm was much ticus, prepared according to Dr. W. Roberts' directions. No thickened, and adherent to the liver, but no nodules were marked advantage resulted from this. On the 19th symptoms of consolidation of the base of the i observed in it. Ileum into the colon .* Gangrene. right lung appeared, and advanced slowly but steadily ; she IV. Intussusception of the 35 years, was admitted into the got a troublesome cough; the diarrhoea was sometimes a Mahomedan, age Sadi, better sometimes worse ; the motions now always contained dispensary on 13th September 1880; he had been ill for twentyplenty of bile ; the tongue was clean, but small and smooth, one days; the illness began with pain in the belly and constit. e. had lost much of its epithelium. The discharge of bile pation ; some native quack gave him several powerful purgathat he was purged about 100 and pus from the tube became quite insignificant, but that tives, the result of which was his there was still a large cavity was shown by the way the times in twenty-four hours ; to pain continued and a lump act. On examination the injection passed in ; the pneumonia progressed, the posterior appeared, the bowels ceased little third of the lung became quite solid ; the morning tempera- patient was found to be feverish, pulse quickened and a w
