when nearly a pint was discharged in the space of twenty-four hours, and during this time but little escaped from the wound. After this period, for nearly two weeks, the discharge was greater or less from the wound in proportion to the amount of purulent matter expectorated and vice versa. The matter from both places being of the same quality and occasionally tinged with blood.

At the end of two weeks from the time the communication between the trachea and the original suppurating surface appeared to have been established, the purulent expectoration began gradually to subside, and the patient's condition slowly to improve until the end of seven weeks after the operation, when he left the city. There was no perceptible motion of the left lung at this time. He was considerably fatigued by his journey from the city to the country, and appeared worse for several days in consequence, but eventually began to improve rapidly, and continued to do so until three weeks since, at which time, as is well known, he visited this city, and was so improved as not to be recog nized by medical men present at the operation, who had seen him every day for some weeks after.

Aug. 1st.-Present condition.-The external wound has entirely cicatrized. No cough nor pain in the left side-good appetite, and all the functions of the system well performed.

The left breast is somewhat sunken, but the upper lobe of that lung has recovered in a great degree its former action.

ART. 102.-Two cases of Intestinal Obstruction in which the Colon was opened in the left Inguinal Region. By Mr. CURLING, F.R.S., Surgeon to the London Hospital.

(Lancet, Jan. 30, 1858.)

Operations for the formation of an artificial anus in cases of insuperable obstruction of the lower bowel from various causes have been performed in so many instances with a satisfactory result, that the operation is now regarded as established, and creditable to surgical art. But it still remains undecided which is the best operation; the inguinal, in which the peritoneum is opened and the anus formed in the sigmoid flexure of the colon; or the lumbar, in which an anus is established in the loin by an opening made in the descending colon external to the peritoneum. Mr. Cæsar Hawkins, in a valuable communication to the "Medico-Chirurgical Transactions," in 1852, gave a table of fortyeight cases of artificial anus, and after a careful comparison of the results of the two operations, came to the conclusion, "that each operator, weighing the advantages and disadvantages of an artificial anus in front of the abdomen, and of one in the lumbar region, is, as yet, fairly justified in selecting whichever situation he thinks best on the left side of the body." The point to be determined is an important one, and the following particulars of two cases in which the author has recently had occasion to perform the lumbar operation are adduced with the view of adding to the recorded facts, and of pointing out difficulties liable to be encountered by the surgeon. In 1852, Mr. Curling opened the colon in the left loin, for the relief of an obstruction from rectal disease. The patient recovered, and returned to his home in Scotland, where after some months he died. In this instance, the descending colon was found fully distended and was readily opened. Such was not the case in the following operations.

CASE 1.-Elizabeth P―, a tailoress, æt. 40, was admitted into the London Hospital, Feb. 24th, 1856, on account of obstruction of the bowels of four weeks' duration. She was a married woman, and had borne a large family. She had never suffered from constipation, nor had she observed any diminution in the size of her motions previous to her present illness. In her last confinement, two months ago, she had less hemorrhage than usual, but both before and since she had been subject to severe leucorrhoeal discharges, accompanied with violent pains in the lumbar region. Four weeks since, her bowels were quite regular. On going to the closet on the twenty-eighth day prior to her admission, she found great difficulty in relievingher bowels, and,

after considerable straining, passed a small amount of feculent matter of the usual size and consistency. Since that period she had passed nothing but a small quantity of slimy matter. She sought medical advice, and took aperient medicines, but without relief. At this time she had pain in the right iliac region, extending to the umbilicus, and loss of appetite, but no sickness. Enemata were administered, and she afterwards took croton oil. This was followed by increase of pain, and violent vomiting every quarter of an hour. The day prior to her admission she was sick about twelve times; all her symptoms were increasing in severity, and she was unable to bear the weight of the bedclothes on the abdomen. By morphia, sinapisms to the abdomen, ice to suck, small quantities of brandy and soda-water, her symptoms were mitigated, and her stomach was able to bear beef-tea and arrowroot. I first saw her the next day, the 25th. Vomiting had quite ceased; her countenance was anxious and cachectic; pulse 120, and weak; abdomen greatly distended and tympanitic. On examination per anum, I discovered at the distance of three inches, a close, carcinomatous stricture of the rectum. On passing my finger into the vagina, I found the indurated, scirrhous mass to be considerable. Mr. Luke saw the case with me, and proposed the passage of a large gum-elastic catheter through the stricture, and the injection of warm water, with the view of breaking up the fecal matter. This was done after considerable difficulty, and about a pint of water injected, when a small quantity of feculent matter came away. But as I found that adequate relief could not be obtained in this way without forcible dilatation of the diseased parts, and the passage of a larger tube, I desisted from further attempts, and proposed the operation for artificial anus, which was performed the next day (the 26th), chloroform being given. In the left loin, which was distended and prominent, I made a transverse incision, two fingers' breadth above the ileum, its centre being exactly midway between the anterior and posterior superior spinous processes. After the division of the layers of muscle and the fascia transversalis a quantity of fat was exposed. On separating this, the peritoneum was brought into view. Careful search was made for the colon, and the wound was dilated towards the spine, the sacro-lumbalis being partially divided, but the intestines could not be found. I was obliged, therefore, to open the peritoneum, when a quantity of serum escaped, and a portion of small intestine protruded. Passing my finger into the cavity, I discovered the colon, contracted and compressed against the spine by the distended small intestine. I drew the colon into the wound, and laid it open by a longitudinal incision, about an inch and a half in length. The sides of the gut were then secured to the lips of the wound by sutures. Very little blood was lost in the operation, and only two vessels required ligature. She was carried to bed much exhausted, her pulse being scarcely perceptible, and placed in such a position on her side as made the opening depending. Some hot brandy-and-water and two grains of opium were given immediately. In a few hours a large quantity of fecal matter passed from the anus in the loin, which gave her great relief. The opium was repeated, and under this treatment, with support, she recovered favorably from the operation, and gradually regained strength sufficient to enable her to get up and walk about the ward. The wound healed, and the inconvenient escape of gas and feculent matter was prevented by means of a hollow pad and elastic bandage, constructed by Mr. Bourjeaurd. The opening in the colon evinced no disposition to contract, and the motions escaped easily. She continued, however, to suffer from pains in the sacrum, and, after some weeks, her health evidently appeared to be giving way. At her own wish, she left the hospital on the 9th of April, and returned home, where she lingered until the 20th, when she died, having survived the operation nearly two months. No autopsy was allowed. CASE 2.-Mr. S-, a stout man, a tradesman, æt. 40, of a pale, sallow complexion, consulted me, at the recommendation of Dr. Munk, in December, 1855, on account of disease of the lower bowel. It appeared that he had been subject for some months to bleeding from the rectum, and to occasional constipation, and that he had latterly lost flesh considerably. Slight bleeding was first noticed upwards of a year before, but it had increased a good deal within the last

few months. On examination, I found a carcinomatous stricture an inch and a half from the anus, the coats of the bowel being much thickened and extensively diseased. I painted the diseased surface with a solution of nitrate of silver, and prescribed astringent injections and cod-liver oil, with a nourishing diet. Under this treatment the bleeding ceased, and he improved somewhat in strength. I saw him occasionally during many months, chiefly in consequence of increasing difficulty in relieving the bowels, and of pains referred to the sacrum. The latter were relieved by morphia, and opiate and belladonna plasters to the sacrum. I found that the carcinomatous growths were filling up the rectum and extending downwards; and when I visited him in the beginning of September, 1856, there were growths projecting at the anus. passage was so contracted that I could not pass the tip of my little finger into it, and no motions passed but in a liquid form, and after laxative medicine, and there was a slimy discharge tinged with blood. His strength, however, had not suffered materially.

The

Sept. 26th.-I was summoned to visit Mr. S in consequence of inability to relieve the bowels. There had been no motion for eight days. He had taken castor oil, senna, Epsom salts, and purgative pills, and, though not suffering any particular inconvenience from constipation, he was getting alarmed, and afraid to take food. His abdomen was soft, and not much distended. His tongue was clean, and he had a tolerable appetite. I attempted to pass a small elastic tube, but could not get it further than two inches, and the water injected all returned. During the last twenty-four hours his urine had been tinged pretty deeply with blood, and he had experienced some pain in the penissymptoms which indicated the extension of the carcinomatous disease to the urinary passages. Finding the development of carcinomatous matter so great, and the obstruction so complete, I felt it my duty to suggest the operation for artificial anus. I fairly represented to my patient that the operation was not free from danger, and that if he recovered from it he could expect only a short prolongation of life, and that not without suffering. The symptoms not being urgent, I did not press for an immediate decision. All aperient medicines were forbidden, and as much food was to be taken as the stomach would bear. On visiting him the following day, I found him anxious, but in no respect worse. He had taken more food and a little wine. There was no tension of the abdomen; but no feculent matter had passed, and his urine was still tinged with blood. He gave his consent to the operation, which I performed the following day (the tenth day of obstruction), assisted by Mr. N. Ward.

28th. The patient had continued to take food, and was much the same as the day before. When he was placed in a convenient position, with a pillow beneath the abdomen, the left loin was not particularly prominent. Chloroform was given, and the incisions were made as in the preceding operation, but of greater size, as the patient was a muscular subject. Having divided the layers of muscle, and the deep fascia, I separated some considerable masses of fat at the bottom of a deep wound, and sought for the posterior part of the colon. This was not found without much search, and the division of the outer edge of the erector spinæ muscle. Having drawn the bowel to the outer wound, I made a free longitudinal opening into it, and secured the edges to the margin of the wound in the integuments with four sutures. The operation was difficult and tedious, and during the time it occupied the patient was kept under the influence of chloroform. Very little blood was lost; but four vessels required to be tied. An opiate was given shortly after the operation, and in the evening he was calm and free from pain. There had been only two small evacuations from the wound..

29th. The patient had slept little, and had lost all appetite. No feces had passed, but there was no tenderness in the abdomen, or in the wound. In the evening he was much troubled with nausea and occasional vomiting.

On the 30th, learning that no feces escaped, I passed my finger into the ascending colon, which I found loaded with soft feculent matter. He had taken very little nourishment since the operation, and his pulse was weak. The bowels were well relieved next day by a mild aperient draught, but the irritability of the stomach continued to distress him, and he took scarcely any

PART XXVII.

10

food. Effervescing ammonia draughts, ice to suck, brandy, hydrocyanic acid, chloric ether, counter-irritation over the stomach, all failed in quieting the organ. He gradually grew weaker and more emaciated, and on the 6th of October, the eighth day after the operation, some bleeding took place from the wound. He lost between three and four ounces of blood before assistance could be had, but the hemorrhage was readily stopped by a little pressure. The bleeding, which occurred with the urine, soon ceased after the operation, but nearly all his water passed by the anus, rendering him constantly wet and uncomfortable. His stomach at length became quieter, but he still took scarcely any nourishment, and no animal food. The evacuations took place readily, and without pain; but the wound made no progress in healing. He got weaker from day to day, and died on the 13th, having survived the operation fifteen days. Permission to make an autopsy was refused.

In both these operations I was disappointed in not finding the colon distended, a condition which greatly assists the surgeon in his endeavors to open the bowel without injury to the peritoneum. In the first case, after a month's obstruction at the rectum, not only was the colon contracted, but it was actually compressed against the spine, and put out of the way by the distended small intestines, so that it was really impossible to reach the bowel without opening the peritoneum. No inflammation or unfavorable symptom resulted, which must be attributed in a great measure to the free use of opium, coupled with good nourishment and support. In the second case, the operation was resorted to on the tenth day of obstruction, and the patient had been able to take food so well that a loaded colon might have been fairly looked for. The bowel was not indeed compressed and displaced, as in the first case, but it was not distended sufficiently to facilitate the operation; and the patient being a stout man, I found it no easy task to reach the colon, and to open it behind the peritoneum. These difficulties are mentioned, not with the view of disparaging the lumbar operation, but to invite attention to obstacles which may arise in its performance. My own opinion leans favorably to this operation, in preference to the inguinal, in cases of obstruction from disease of the rectum. In a spare subject, with the colon moderately distended, the operation is not very difficult, nor one attended with any great risk to life; and after the wound has healed around the opening of the bowel, some such contrivance as that used in the first case will greatly obviate the inconveniences of the anus in the loin. Even if the peritoneum be wounded, it may be questioned whether, under judicious treatment, the dangers of the operation are much increased thereby. In the second case, the operation can scarcely be said to have prolonged life, for without it the patient, by careful management, would probably have lasted as long. The prime object of the operation was accomplished in enabling him to relieve his bowels freely; and I attribute the unfortunate result chiefly to the unfavorable influence of chloroform in this instance. That chloroform does occasionally give rise to an irritable state of the stomach, of some duration, is well known. Mr. S- inhaled an unusually large quantity of it, and was kept under its influence nearly three-quarters of an hour, in consequence of the difficulties of the operation. He was well able to take food previously, but afterwards lost all appetite, and became troubled with nausea and vomiting, which lasted some days, even after the bowels had been well relieved. The inability to take nourishment, especially animal food, was the chief cause of his sinking; for no peritonitis ensued, and the wound assumed no unfavorable condition until his powers became reduced by want of nutrition.

ART. 103.—On Abdominal Subcutaneous Emphysema. By Dr. O'FERRALL.

(Dublin Hospital Gazette, March 1, 1854.)

Emphysema has been described with great accuracy by Hunter, Bell, and others; but the emphysema of authors is that produced by escape into the cellular tissue of atmospheric air modified by the products of respiration. As hitherto observed, it is generally confined to the parietes of the chest and the neighboring regions of the neck, although its extension to other parts of the body is verified by the records of surgery. The emphysema, however, which

originates in inflation from the intestinal canal, and most generally occupies the abdominal regions alone, and in this place gives rise to a swelling likely to be confounded with disease of the abdominal cavity, is now, we believe, for the first time described.

"Abdominal subcutaneous emphysema," says Dr. O'Ferrall, in a clinical lecture delivered at St. Vincent's Hospital four years ago, "is rapid in its formation, and distressing in its effects; and the sufferer will be impatient if any hesitation as to its nature be displayed. I trust, therefore, that the short description which I shall now give you may be sufficient to enable you to recognize this remarkable lesion, when presented for your opinion.

"It is, as I have said, rapid in its formation, and the practitioner may receive an early summons to see a tumor as large and as tense as a dropsy; and he may be told that at bedtime, the previous evening, no trace whatever of this condition had been observed. The tumor or swelling may, on inspection, be found to occupy the whole area of the abdominal parietes, as well vertically as in the transverse direction. It may be colorless, or, indeed, even remarkably pale. The skin is smooth, even shining and tense. On manipulation, this tension is found to differ materially from that arising from liquid effusion into the peritoneum, or that of an ovarian or other cyst. The integument is tense, but not resisting. The least and lightest pressure of the finger displaces it, but it instantly returns and leaves no pit or trace behind. There may, over the whole anterior middle portion of the abdomen, be no crepitation to mark its real nature, and, as yet you may have only a suspicion arising from the difference between the sensation then conveyed, and that with which experience had rendered you familiar, in cystic or other liquid accumulations. A light and springy percussion now elicits an unequivocal tympany, but short and faint, and, indeed, unlike any you ever heard before. Still it is tympany, however faintly marked. You now trace the swelling laterally towards either loin, and here a distinct crepitation is detected. It is similar, in all respects, to that which is met with over the neck and chest in cases where, from any cause, an abnormal communication is established between the air-passages and the general areolar tissue. This crepitation may, perhaps, be detected also towards the inguinal regions, but is generally absent in the middle portion of the swelling. In the course of this examination, which is rapidly accomplished, you may now discover some blush in the integument, and further on a redness of greater or less intensity, and generally of a dusky hue. You are now approaching the real seat and source of the disease. The seat of this discoloration is different in different instances; but we shall suppose that, on approaching the sacral or gluteal regions, you find the discoloration most remarkable, and that here the parts beneath the skin have that peculiar feel to which the term 'boggy' has been applied. What history shall you be likely to receive, on inquiry into the case? If the patient has not had competent advice, and has not been made acquainted with the nature of his malady, you will be told that for a long time, perhaps years, there has been constipation, pain in defecation, occasional hemorrhage, mucous or puriform discharges, and that he has suffered, as he believes, from aggravated piles. You proceed to examine the rectum, and you discover some one of the various forms of organic disease of that part, diminishing and obstructing its calibre, and producing that state, which an imperfect and superficial pathology has often described, under the name of stricture, as the essential disease. The emaciated condition of the patient is in accordance with the result of this investigation, and you have now a solution of the problem. There has been, in fact, perforation of the coats of the bowel. The natural attempt to limit, by what has been called adhesive inflammation, the depot thus formed, has failed; or some impulse or disturbance has broken through its lining of lymph, and the cellular tissue has become injected with the gaseous contents of the intestine. If the case has been in competent hands, you will be made acquainted with the fact, that disease of the rectum has been recognized, although the present accident may not have been anticipated.

"That which I have now described is one source of emphysematous tumor of the abdomen. The case lately in Mary's Ward is still in your recollection, and you will remember the rapidity with which, in that case, the abdominal swelling was produced.