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and ureteral pain being caused obviously by the drag of thegrowth upon the ureteral orifice. The patient was saved auseless nephrotomy, which was certainly indicated by thesymptoms.CASE 3.-The patient, a male, aged 61 years, had suffered

for four years from an enlarged prostate complicated bycystitis and the formation of phosphatic calculi. On threeoccasions litholapaxy had been performed. For nine monthshe had been absolutely dependent upon the catheter, thecystitis had increased and was only kept in check by washingout the bladder twice daily, and the sound revealed thepresence of another stone. The prostate, per rectum, wasfound to be moderately enlarged, both lateral lobes being ’’

about equally involved. The advisability of suprapubicprostatecbomy was considered, but before proceeding to thisradical measure cystoscopy was advised to ascertain thecondition of the prostate on its vesical side. The cystoscopeshowed a stone, one inch in its longest diameter, lying under,and half hidden by, a pendulous median enlargement of theprostate. This adenomatous mass, of the size of a small

walnut, was attached to the main body of the prostate by adistinct though short pedicle. A small median perinealincision sufficed to remove both stone and growth and toprovide for adequate draining to cure the cystitis. Thewound healed in a fortnight and during the 20 months whichhave elapsed since the operation this patient has had com-plete control over his urine, which remains clear, and has hadno further stone formation. Here, by the aid of the cysto-scope, a simple operation was substituted for one much moredangerous and the period of convalescence was reducedby one-halt.CASE 4.-The patient was a male, aged 34 years, who had

suffered from four or five attacks of profuse hasmaturia duringa period of nine months. The attacks lasted from one tofour or five days and were unattended by other symptomssave some pain from the passage of clots and occasional dullaching in the left loin. Physical examination failed to revealanything further, but the cystoscope showed me a large singleulcer to the inner side of, and below, the orifice of the leftureter. Tubercle bacilli were afterwards found in the urine.Under appropriate treatment the ulcer gradually healed, theprocess being watched from time to time by means of the.cystoscope until healing was complete. This patient hasreturned to his work as a postman and has kept well duringthe past nine months. Could this diagnosis have been madewith equal certainty by any other method ? and without theoystoscope would not this patient have been subjected to asuprapubic exploration ?

CASE 5.-The patient, a male, aged 61 years, sufferingfrom severe intermittent haemataria with pain on micturitionand increased frequency, I found on examination with theoystoscope to be suffering from carcinoma of the bladderchiefly implicating the posterior wall and trigone, but of so,extensive a character as quite to contra-indicate any operativeinterference. Growth of the bladder was diagnosed, it is Itrue, before cystoscopy, but the nature of the growth was I-doubtful and the cystoscope alone could settle the advisability- or otherwise of operation.CASE 6.-The patient was a male, aged 45 years, who

suffered from three quickly repeated attacks of violent hasmat-uria without any other symptoms to account for the trouble.He was in good general health and complained of no pain- except that caused by the passage of clots along the urethra.He came from the country, a long journey by rail, for exa-mination. Nothing could be felt either abdominally or perrectum to throw light upon the case. The railway journeystarted the bleeding afresh and on the following morningon attempting cystoscopy the bladder was found to be halffull of soft clot and the bleeding was still proceeding. Insuch circumstances cystoscopy was impossible and as fromthe severity of the haemorrhage and the bright red colour ofthe blood it seemed probable that its source was vesical thebladder was opened suprapubically but was found to containonly clot No further bleeding occurred whilst the woundwas healing but on rising for the first time some 14 dayslater another slight haemorrhage took place. The furtherhistory of this case is sad in the extreme. Six weeks after’operation the left kidney was felt to be enlarged, the firstdefinite indication of the site of the disease. The patientwas warned of the probable nature of the disease but refusedto undergo another operation so soon after the suprapubiccystotomy. Within six months death took place from meta-static deposits of sarcoma in the brain, whilst other masseswere found in the lungs and liver. This patient lost his only

chance by neglect to verify the diagnosis by cystoscopy, forthough he was quite willing to submit to one operation hecould not bring himself to face a second within six weeks ofa first so barren in results. Had he been kept at rest untilthe bleeding had sufficiently abated to render cystoscopypossible the kidney would have been removed with a fairchance of success.

Conolusions.-The cases here described have been chosenfrom the records of cystoscopies which I have madeduring the past five years. They are sufficiently strikingto vindicate the position which I claim for the cysto-scope as a diagnostic instrument of the first importance.I could narrate many other cases of a like nature whichI have examined, or have seen, in the practice of other sur-geons. The only objections which can be urged against thecystoscope are those which apply with equal directness tometal instruments of a like calibre In the great majorityof cases the examination can be conducted under localanxsthesia induced by the injection of eucaine, and I candeliberately state that I have never yet seen more seriousafter-results from the proper use of the cystoscope than thosewhich might follow the passage of any other instrument. Incases of disease of the urinary organs where the diagnosis isdoubtful I consider that no examination is complete whichdoes not include the use of electric cystoscopy.

I wish to express my acknowledgments to Mr. Reginald

Harrison for permission to publish the cases.

Lower Berkeley-street, W.

AN UNUSUAL CASE OF MATTING OFINTESTINES FOR WHICH DOUBLEENTERECTOMY WAS PERFORMED

SUCCESSFULLY.

BY BILTON POLLARD, B.S. LOND., F.R.C.S. ENG.,SURGEON TO UNIVERSITY COLLEGE HOSPITAL.

DOUBLE enterectomy is, I believe, very rarely neededexcept in cases of gunshot injury and so I think that a casein which such an extensive operation was performed fordisease is worthy of record. But apart from the unusualcharacter of this case I think that all cases of operation onthe intestines should be reported for some time longer inorder that we may be provided with facts from which todetermine, in the first place, the symptoms which in chroniccases should lead to an exploratory operation and, in thesecond place, that we may, by comparing cases with oneanother, both as regards the operative technique adoptedand the immediate and remote results of the operations,arrive at more definite conclusions with regard to thesematters than have hitherto been formulated.

I propose shortly to publish a series of cases in which Iremoved portions of the colon for chronic intestinal obstruc-tion due to malignant disease, but this case, although itinvolved the removal of several inches of the colon, does notproperly belong to that series because there was no malig-nant disease in this case and because it was nccessary inaddition to the piece of large intestine to remove three feetof small intestine.The patient was a woman, aged 57 years, whom I saw

in consultation with Dr. J. P. A. Gabb on May 25th, 1902.Her father died from cancer. She herself had been healthyand free from any definite symptoms of illness till November,1901. She then only complained of vague dyspeptic sym-ptoms with pain about the umbilicus and epigastrium.During the winter months she lost flesh and her complexionbecame gradually more and more sallow. In March, 1902,she was taken ill with influenza, complicated with diarrhoeaand sickness. On March 24th a swelling was detected in theabdomen and Dr. Gabb was called in in consultation witha view to operation. The swelling proved to be due toflatulent distension of intestinal coils-very probably the ballof intestinal coils removed at the operation. The bowelswere not obstructed and there was no visible peristalsis.The patient returned home in order to be under Dr. Gabb’scare on the 27th and from that date to May llth she wasalways more or less ailing with pains in the lower part ofthe abdomen which had no special relation to food, and shewas always more or less constipated. The bowels alwaysresponded to aperients and there was never any real obstruc-tion, although there was a good deal of flatulent distension

872

of the bowels. On May llth a severe heamorrhage fromthe bowels occurred. This was not repeated. The patientwas now seen by Dr. J. F. Goodhart who thought that therewas probably a malignant growth in the upper part of therectum and pronounced the case to be one for surgicaltreatment. I saw the patient with Dr. Gabb on the 25th.There was some general distension of the abdomen butno obstruction. No lump could be made out in the course ofthe colon. The rectum, as far as could be reached by thefinger, was normal, but feeling through the bowel at theextreme limit to which the finger could reach, it was possibleto detect an indistinct swelling which suggested the presenceof a growth in the bowel higher up either in the sigmoid loopof the colon or in the upper part of the rectum. The

frequent abdominal pains, the flatulent distension of thebowels, the loss of flesh, and the haemorrhage all tended tosupport this view.On May 27th I operated at the patient’s home. Dr. Dudley

vV. Buxton gave the anxsthetic and I was assisted by Dr.Gabb and Dr. P. Levick. As no tumour could be felt withcertainty a median incision below the umbilicus was made inorder to explore and this proved to be the best situationwhich could have been selected if the condition of the intes-tine had been known beforehand. A hard mass surroundedby intestinal coils was at once felt in the pelvis and after theincision had been extended from the umbilicus to the topof the bladder it was possible to lift the mass out ofthe pelvis and to bring it out of the wound. A goodidea of this mass can be obtained from the annexed repro-duction of a very accurate drawing of the parts removed at

the operation. It was composed of intestinal coils whichtogether formed a mass of about the size of two fists. Onthe left side was a piece of the sigmoid loop of the colonabout seven inches long and on the right side were coils ofileum, measuring rather more than three feet in total length,which were adherent to one another in many places andwere darkly congested. The mesentery was much thickenedand the colon was very firmly adherent to it. At the site ofthe adhesion there was a dense mass which appeared to all ofus to be a tumour of the colon which had become adherentto, and had invaded, the mesentery. The illustration depictsthe appearance of the mass of intestines as seen from behind.There are more coils of the ileum on the other side whichcannot be shown. The divided mesentery is well seen andthe sigmoid mesocolon, which was divided close to the bowel,is sufficiently indicated for identification. The whole mass wastethered to each side of the abdomen near the iliac fossa, onthe left by the sigmoid mesocolon and on the right by themesentery. After making some attempts to separate the

adhesions between some of the coils it became obvious thateither the operation must be abandoned or the whole ballof adherent coils of intestine must be removed-an operationwhich would involve section and suture of the sigmoid loopof the colon and section and suture of the small intestine.I’he latter alternative being decided upon a quantity of plainsterile gauze was packed into the wound so as thoroughly t&isolate the rest of the abdomen from the field of operation.The small intestine was dealt with first. The course of theblood vessels in the mesentery was noted in order to deter-mine the places where the bowel could be divided withoutjeopardising its circulation, for, as shown in the illustration,the mesentery had to be divided at a considerable distancefrom the small intestine owing to the colon being inseparablyadherent to it. It may appear from the illustration thatmore small intestine was removed than was absolutelynecessary. This was not so, however, and, indeed, it may besaid that no greater mistake can be made in enterectomythan by removing too little bowel to jeopardise the circula-tion in the sutured ends. The ileum on each side of themass of adherent coils was divided between a clamp and a,ligature, the ligature, of course, being placed on the piece ofbowel which was going to be removed. The divided ends ofthe bowel were disinfected and temporarily plugged withgauze whilst the mesentery was being tied in segments anddivided just beyond the place where the loop of colon wasadherent to it. As a rule it is preferable to separate all theattachments of a piece of bowel to be removed before thebowel itself is divided but in this case, owing to the adhesionbetween the colon and the mesentery, it was difficult to tieoff the mesentery before the bowel was divided. The baitof adherent coils of intestine was now free from the rest ofthe small bowel and was drawn over to the left side andwrapped up in gauze whilst the suturing of the small intestinewas proceeded with. The bowel was sutured end to end withtwo rows of simple continuous sutures-a method which isjust as easy to apply as, and in my opinion far safer and inevery way more satisfactory than, the various mechanicalcontrivances which have been devised for enterorrhaphy.The two ends of the bowel were first of all fixed togetherby an interrupted stitch at the mesenteric attachment andthen the first row of continuous stitches was inserted fromthe mucous surface through all the coats of the bowel. Thestitch was commenced at a point about one-third of the cir-cumference away from the mesenteric attachment and owingto the skilful way in which my assistant held the bowel, atfirst with his fingers and later with forceps, it was possibleto stitch from the mucous surface for fully five-sixths ofthe circumference. The final sixth had to be stitchedfrom the peritoneal surface which takes more time andis less efficient than stitching from the mucous surface.The weak part of the first row of stitches-the final sixth-was at a part of the bowel far away from the mesenteryand therefore favourably located for being securely con-trolled by the second row of continuous suture whichwas applied from the peritoneal surface according to

Lembert’s method and penetrated all the coats except themucous. The gap in the mesentery was closed by a con-tinuous suture on each side which was also insertedaccording to Lembert’s plan and was prolonged on to thebowel for about a third of an inch. The bowel in the neigh-bourhood of the suture line was dabbed with 1 in 1000solution of perchloride of mercury and then washed withsterile salt solution. The gauze packing was now removedand the sutured bowel was dropped into the abdomen.Fresh packing was applied so as to protect the abdominalcavity and then in a manner corresponding to that justdetailed the sigmoid loop of the colon was removed. Afterthe sigmoid mesocolon had been ligatured and divided andthe colon itself was cut on each side beyord the adherentpart, the ball of adherent intestinal coils figured above wasentirely free and was removed. The colon was united bytwo rows of continuous sutures and the wound in the sigmoidmesocolon was stitched upon each side. The gauze packingwas then removed and the colon was returned to theabdomen. The abdominal wound was stitched up in threelayers and dressed with plain sterile gauze.About three hours after the operation the patient was

recovering consciousness. There was very little shock. Her

temperature was 99° F. and her pulse was 120. Dr. Gabbtook charge of the patient and -he got on so well that it wasunnecessary for me to see her again. On the day after theoperation the pulse-rate rose to 130, but by the second dayit had fallen to 112, and on the third day it was as low as 90.

873

For the next ten days it varied between 90 and 100 andafterwards it kept below 80. The highest temperature,99’80, was registered on the day after the operation and onand after the second day the temperature kept below 99°.The patient remained remarkably free from pain or abdominaldiscomfort; she got a fair amount of sleep and no morphia wasneeded ; her tongue kept moist and there was no abdominaldistension. Rectal feeding was continued for eight days.A suppository of beef and milk peptone and a nutrient enemaof an ounce of liquid peptone and three ounces of water weregiven alternately every four hours. The rectum was washedout daily. As soon as the patient recovered from the anaes-thetic she was allowed two drachms of water by the mouthevery half hour and after 24 hours she took two drachms ofliquid peptone and two drachms of water every hour. On thethird day the quantity was doubled and sometimes instead ofit an ounce of milk-and-water was given ; four ounces ofmilky tea were given in the afternoon and this was repeatedeach day Oa the fourth day either an ounce of liquidpeptone and an ounce of water or a similar quantityof milk-and-water was given hourly. On the seventh

day the dose was doubled and given every two hours.On the eighth day, after the bowels had acted, fiveounces of Benger’s food were substituted for one of thesefeeds. The Benger’s food was soon increased to eight ouncesat a time, but otherwise there was not much change until thefourteenth day when egg-and-milk and pounded chicken weregiven. On the sixteenth day rusks were added to the dietary.It is unnecessary to follow the diet farther. On the second

day after the operation flatus was passed through the rectaltube freely ; on the third day, and afterwards, flatus was passednaturally and also through the rectal tube which was insertedwhenever the patient felt the presence of flatus which wasnot readily voided. On the eighth day five ounces of oliveoil were injected into the rectum and four hours later anenema of a pint of soapy water was given and the bowelsacted well On the following day the patient passed aformed motion naturally. Afterwards the bowels generallyacted every other day, sometimes without and sometimesafter an enema.

The abdominal wound healed by first intention and thestitches were removed on the eleventh day after the opera-tion. On the twenty-second day the patient left her bed andlay on the couch for three hours. Nine months after theoperation, except that her bowels were rather constipated,the patient was quite well-indeed, she was reported to beenjoying better health than she had done for several years.

It only remains to add that the diagnosis of carcinomawhich was made on the symptoms and which was thoughtto have been verified at the operation was incorrect. Themucous membrane of the bowel looked quite healthy and themass between the colon and the mesentery was due toinflammatory thickening. The bleeding had probably takenplace from the small bowel, the coils of which were greatlycongested. This may have resulted from pressure on theveins owing to a slight twist of the mesenteric pedicle ofthe mass of intestinal coils. There is nothing in the

patient’s history to explain the cause of the matting togetherof the intestinal coils. The pelvic organs seemed to benormal and there were no adhesions between other intestinalcoils. The rest of the abdomen seemed to be quite healthy.The specimen is now in the museum of University College,London.

Harley-street, W.

TREATMENT OF A FORMIDABLE CASEOF SPRUE BY DIET ; THE VALUE

OF STRAWBERRIES.BY EDWARD H. YOUNG, M.D. DURH., L.R.C.P. LOND.,

M.R.C.S. ENG, L.S.A.

A WOMAN, aged 59 years, whose medical history is detailedbelow, came under my care in 1901. It appeared that shehad lived in India for some 24 or 25 years with intervalswhen she came to England to visit her children. She wasnever a strong woman, but she had never suffered from

any serious disease either in England or in India. She

finally left India ten years before the present illness.For the two years prior to coming under my care she

had much anxiety about the health of one of her I

children. Always a woman of extremely active habits,she ate very little and became ansemic and sallow,over-exertion often producing attacks of migraine and

i.euralgia. In 1900 the patient had had a prolonged andexhausting period in nursing another of her childrenthrough an attack of acute rheumatism. Very earlyin 1901 she suffered from a very serious attack ofinfluenza, towards the close of which she was attackedwith a nocturnal diarrhoea.. Her convalescence fromthe influenza was slow and as its symptoms dis-

appeared, those of sprue became apparent. The diagnosisof sprue was confirmed by Dr. John Anderson, C.I.E.,who saw the patient at the time and again a fewweeks later. The patient steadily refused to adopt a

milk diet, though strongly urged to do so by Dr. Anderson,and her diet consisted chiefly of meat-juice, plasmon, soup,oranges, grapes, and plantains, a little bread-and-milk andmilk puddings. From the onset of the symptoms of spruethe patient had steadily wasted and lost strength. I learnedthat she had been a well set-up and active woman of about8 stones’ weight and that she looked considerably below herreal age. She had been wholly confined to bed and wasremoved for change-a proceeding which was attended withgrave risk.I first saw the patient, who was lying in bed, on Nov. 2nd,1901. She complained chiefly of severe cramps in thelimbs, more especially on the left side, which came on theprevious evening. There were further complaints of chronicdiarrhoea, soreness and rawness of the mouth, and pro-gressive weakness and loss of flesh. She was so emaciatedthat the bones projected under the skin and the wastedmuscles were easily traced. The tongue was denuded ofepithelium, with ulceration at the tip and sides. Theabdomen was distended and slightly tender on pressure ; itsattenuated parietes displayed the coils of distended intes-tine. The liver and spleen were not definable on account ofthe abdominal distension. The motions were of the typicalsprue character-very large, pultaceous, ochreous, sour-

smelling, frothy, and very frequent. The heart sounds werenormal and the lungs also were normal. The pulse was 104 ;it was regular in force and rhythm and of good tension.The temperature was 100’ 6° F. The urine was normal. Thehands, the feet, the arms, and tte legs were rigid in the *

typical position of tetany, causing the patient great agony.A hypodermic injection of morphia was given ; it affordedmarked relief to the painful spasms and produced somesleep.

During November there was a steady decline in strength,but the patient still insisted on getting out of bedunassisted. With the view of keeping the carbohydratesas low as possible the diet was of a mixed character,consisting of soup, fish, game, &c., but small quantitiesof bread and porridge were allowed, with grapes, plantains,and s’ewed pears. The actual amount of ingesta was,however, very small, most things being merely tastedor inspected and then put aside. The patient still deter-minedly declined to adopt a milk diet, though this was

repeatedly urged upon her. There were one severe repetitionof the attack of tetany and one or two minor ones. Onthe first of these occasions a spasm of the larynx causedmuch alarm and necessitated the administration of chloro-form. The medical treatment was purely symptomatic.Bromide of potassium and antipyrin had some effect in

relieving the minor spasms. Salicylate of bismuth was triedas an intestinal antiseptic but proved practically useless.Opiates in the smallest quantities, combined with otherdrugs, or otherwise, proved hurtful and the mildest

astringents also did manifest harm when once or twice

cautiously tried. The gradual and progressive decline in thepatient’s strength continued in December and the emaciationbecame extreme. There were two or three attacks of thetetany but none of these were severe. The pulse variedremarkably in character, being sometimes soft and then hardand frequently intermittent, all within a few hours. It was

repeatedly noticed that hardness and intermittency of pulsealmost invariably preceded a very large fermented motion.The temperature was generally subnormal in the morningsand about from 990 to 99 50 in the evenings but was easilydisturbed. The attacks of tetany usually sent it higher.Towards the end of December the number of motionsaveraged 6’5 per diem. In size they varied considerablyfrom about 12 ounces of a large, whitish, thick, pultaceous,mass, which moved slowly on the vessel being tilted, to sixor seven ounces of a whitish frothy fluid. These latter, if