The prognosis depends almost entirely upon the nature of the causes and complications. Cases of four months to fifty years duration are on record. Some intercurrent disease is generally the cause of death. Cases of recovery have been reported, and spontaneous cures may take place; but where these occur, the duration is generally within one year and is independent of treatment.

270 Woodward Ave.

DR. METCALF'S CLINIC.

At Harper Hospital, December, 7th, 8th and 9th, 1904.
REPORT OF CASES-CONTINUED

Case XII.

Fibroid of uterus. Metritis. Vaginal hysterectomy. (Dec. 8th, 11:30 to 12:30.)

Mrs. M., aet. 39. Family history negative. Menses began at 14; regular and 5 days in duration. Dysmenorrhoea, with fainting and vomiting during the first day. Fifteen years ago was in hospital 14 months "because of rheumatism following typhoid infection of the bladder." Left knee remained stiff. Has three children, the oldest 11 and the youngest 4 years old. Has had two miscarriages; last one was at two and a half months and was two years ago. Following first miscarriage, five years ago, had sepsis and was in bed three months. Was again confined to her bed through August and September last with peritonitis. (Compare Case IX in this connection.) Patient now has aching through top and back of head and in eye-balls; feels as though head were being constantly drawn backward. She has constant pain and soreness in abdomen, which is always tympanitic.

Suffers from dyspepsia and obstinate constipation, coldness of hands and feet and insomnia. Vaginal hysterectomy was now performed; the uterus was found large and contained a fibroid in the anterior wall at the junction of the cervix with the body of the organ. Both ovaries had undergone cystic changes. Pathological examination of the uterus showed advanced interstitial endometritis and extensive fibrous deposits in the outer muscular layer. Besides the one developed fibroid, there were other small ones found in the microscopic section. The tubes were the seat of large deposits of fibrous tissue and increase of blood-vessels with thickened walls. The plicae were edematous and contained some increase of small cells. The ovaries showed a greatly thickened tunica albuginea.

There were many areas of hyaline degeneration, the blood-vessels were increasd and had thickened walls, and there were old follicular cysts. The reactionary temperature reached 101. but subsided in a few hours; the highest pulse-rate was 100. Both pulse and temperature remained normal after the 6th day. The patient sat up on the 13th day but remained in the hospital until Jan. 7th, when she appeared to be in good condition. On June 1st,she was reported to be in good health, her greatest annoyance being the "hot flashes" that regularly follow for a time the removal of the adnexae. She had been doing her own house-work for the past two months.

Case XIII. Extensive rectum and sigmoid flexure. in clinic, Dec. 8th.)

obstructing fibro-lipoma surrounding the (Removal at operation, Dec. 5th; exhibited

Mrs. F., aet. 59. Tuberculosis on the maternal side. Menses began at 14. Married at 15; had six children; one miscarriage at 7 months; not pregnant since. Menopause at 46. Complained lately of backache, aching in back of head, and distress in lower abdomen; constipation, dyspepsia, tympanites, and frequent urination more especially in the day time. The constipation had been increasing gradually until of late even enemata were with difficulty effective. Three days ago this patient was placed in the Trendelenburg position; exploratory median abdominal incision was made, and a new-growth found surrounding the sigmoid flexure of the colon and upper rectum, crowding upon the pelvic organs, and adhering to the uterus. The growth is of the nature of a fibrolipoma, starting between the two layers of the mesentery and spreading around the bowel so that the latter is practically buried in the mass of rather dense fat. The cross-section of the growth surrounding the bowel varied from 8cm. by 6cm. to 6cm. by 5cm., and the whole was increased by numerous epiploic appendages engorged with fat. The bowel, thus encumbered for a distance of 28cm. (about 11. inches), upward from the middle of the rectum, became in the aggregate a tumor of threatening proportions.

At no part of the bowel thus compressed was any definite malignant histological change engrafted upon the moderate hyperplasia of the It cannot, however, be overlooked that the lipoma was attaining a size which not only must be considered in relation to the bowel itself, but would eventually threaten life by interference with other organs. The bladder had already resented its presence. The removal of the ordinary pedunculated lipomata of the rectum described in the textbooks presents some difficulty if we proceed upon entirely safe ground, but it will readily be seen how absolutely impossible it would be to have removed the growth here involved by any means calculated to preserve the integrity of that portion of bowel contained within it. Accordingly the colon was amputated about five inches above the sigmoid flexure, the iumen having been closed with forceps above and below the line of incision. The lower end of the proximal portion being wrapped in gauze, the mesentery and mesorectum were ligated progressively downward and the rectum amputated at a point as low in the pelvis as accessible. The upper end of the amputated rectum was now grasped by large forceps passed through the anus and by inversion drawn outward through this opening. Next an artificial anus was made in the usual location for inguinal colostomy, the lower cut end of the proximal portion of the bowel being brought up and stitched into the opening. The denuded area in the pelvis was packed loosely with iodoform gauze with end pushed downward into anus and the abdominal wound closed. The patient was then placed in the lithotomy position, the sphincter cut posteriorly, and the remaining portion of the rectum removed. The end of gauze placed from above was brought out and other gauze added to assist drainage. The recovery was uneventful except for a limited suppuration in the abdominal wound, infection reaching it from the colostomy wound. Highest temperature, 102.4; highest pulse-rate, 100. The temperature was normal after Dec. 23rd. She left the hospital Jan. 14th in good condition. The artificial anus needed subsequent dilatation, which was done by her attending physician. She is now (June 5th) in good health and a daughter reports that the patient has good control of bowel movements except during catharsis.

Lipomata are ordinarily attached to the rectal wall and they more. often assume a polypoid character. They are composed of fat-cells enclosed in a fibrous stroma and their vascularity ordinarily is not great. "Vorchung (Trans. Path. Soc. Lond., vol. XV, p. 100), has reported a case seen in a woman who had suffered during life from retention of fæces and difficulty in urination. She died from mechanical obstruction to the passage of urine. Upon post-mortem there was found a lipoma in the pelvis completely surrounding the rectum and firmly attached to its outer walls. The growth entirely obstructed the two ureters and almost completely occluded the rectum."-Diseases of the Anus, Rectum, and Pelvic Colon; James P. Tuttle; p. 718.

Case XIV. Obstruction of cystic duct by enlargement of a lymphgland at the angle between it and the hepatic duct. (Dec. 8th, 12:30 to 1:30 P. M.)

Mrs. S., aet. 49.. Family history negative. Matured at 13; dysmenorrhoea severe. Married at 22; two children, ages 25 and 21. Her suffering during menstruation continued throughout menstrual life. Menopause, eight months ago. She has had discomfort in region of gall-bladder for last 15 years. Is just recovering from last attack, which began six weeks ago. The intervals were formerly of two or three months duration; of late the discomfort is almost constant. Has had chills, sweating, and nausea during last attack; also referred pain to median side of right shoulder-blade. Complains of coldness and constipation. Examination of urine, negative; incomplete examination of stomach contents showed HCl present; haemoglobin, reduced to 60. per cent. No pelvic examination before she was brought into clinic. Exploratory incision in the right hypochondrium. Gall-bladder found to be filled with fluid, which could not be forced out into common duct, the cystic duct being obstructed by an enlarged lymph-node, of the size of a small olive, in the angle at the junction of the cystic and hepatic ducts, together with a congestive thickening of the mucosa. The gall-bladder measured 10. cm. in length and was of paler color than normal. There were a few adhesions apparently of recent origin. The fluid contents were removed by means of the aspirator, and a thick, brownish, semi-transparent, mucous fluid was thus evacuated; an opening was made in the fundus, but no stones were found; and a double drainage-tube was stitching into the opening made, and the organ brought up to the parietal peritoneum.

The patient was anæmic and I felt this a safer procedure at this time than cholecystectomy. I believed that by drainage in this case the enlarged lymph-gland would become smaller, and this was afterward found to be so. Her immediate recovery was uneventful, her highest temperature being 99.8, and highest pulse-rate, 100. She left the hospital Dec. 31st, apparently greatly improved, and with the wound entirely healed. After being up and about for a time she was again annoyed by a troublesome dragging pain in the lower abdomen; she returned to Harper Hospital on April 8th. On making the pelvic examination, which had been omitted in the clinic, partly for lack of time, and partly for absence of positive indications in the history obtained, ample cause was disclosed for her present discomfort-a different train of symptoms, however, as will be observed, from the periodic attacks which had formed her chief complaint on the occasion of her former visit to the hospital. The uterus was sub-involuted and retroverted, and its appendages were firmly adherent. Abdominal hsyterectomy was performed.

Pathological report: Chronic interstitial endometritis. Hyaline degeneration of ovaries, together with increase of their blood-vessels and fibrous tissue; all these changes extensive. Occasional old follicular cyst. Absence of Graafian folicles.

Occasion was taken at this time to examine the gall-bladder. It was found to contain a small quantity of bile, which could be readily pressed through the cystic duct. The gland which formerly had caused the obstruction had become reduced in size, measuring 2 mm. by 3 mm. by 4 mm. The new-formed ligament, attaching the gall-bladder to the abdominal wai, was about 2.5 cm. long with omentum adhering about it. The temperature rose to 102. on April 19th, on account of infection in the abdominal wound; it remained normal after April 27th. She left the hospital May 11th with the abdominal wound, although clean, yet not completely healed, the process of granulation being very slow. On June 12th, her family physician reported that she was apparently well, but that the wound had been slow in healing.

Case XV. Partial atresia of the anus, congenital. Phimosis. (Dec. 8th, 1:30 to 2:30.)

Baby I., aet. 1 year. This baby is healthy and perfectly developed with the exception that instead of the normal anus there is a small linear opening anterior to normal position. Through this opening, defecation has been accomplished with difficulty by the aid of a syringe.

In cases where the occlusion is complete or nearly so, operation should be performed at once, on the first or second day of life, before ileus begins to appear. In some cases the atresia is complete and in such an artificial anus must be made. This case is a simple one to correct, but I will use the same method as though there were complete occlusion by a thin membrane, viz., an antero-posterior incision. Through this incision the rectum is emptied and washed, the redundant tissue trimmed away, and the edge of the mucosa brought down and stitched to the skin. i do not need to cut through the sphincter in this case.

In performing the circumcision, I first dilate the prepuce with these fine-pointed forceps, retract the foreskin, partially clip the frenum, so that the glans penis will not be drawn downward. The foreskin is then pulled forward over the glans, as in its original position; a tenaculum is hooked from within outward through the mucous membrane at both the frenal and the dorsal sides. The foreskin is then put upon some stretch by pulling forward upon the tenacula. A narrow bistoury blade is then passed from side to side through the center of the foreskin at the tip of the glans and carried through, severing the frenal half. With a scissor curved upon the flat, the other half is incised upward over the dorsum. In this way just enough mucous membrane and skin are removed. The edge of the mucous membrane is then stitched to the edge of the skin, the stitch encircling the artery of the dorsum and of the frenum; or interrupted sutures may be used. Swelling and annoying erections are caused by constriction of the veins behind the glans and both may be prevented by pulling the shortened foreskin forward over the glans and keeping it there for three or four days by passing a catgut suture through the center of the foreskin from side to side and tying it above the meatus in this position. To prevent the formation of adhesions between the glans and the inner surface of the prepuce, a layer of collodion, or "liquid court-plaster" may be interposed. Attention to these minor details will keep the baby comfortable.

The baby left the hospital on Dec. 12th, and the attending physician on April 17th reported that the results were satisfactory and the child was well.

Case XVI. Cholecytitis and chronic pancreatitis. Mayo RobsonCammidge test positive. Cholecystectomy. (Operation Oct. 22nd; exhibition in clinic Dec. 8th, for purpose of comparison with Cases V. and XIV.)

Mrs. M., aet. 42. Father died of cancer of the rectum. One paternal aunt died of cancer. Patient matured at 13; normal; married at 21; two children, ages 20 and 13; two miscarriages, last one ten years ago. She was sick for four months after her first miscarriage. Lacerations were repaired three years ago. She had suffered pain in the epigastrium since childhood. Intervals between such attacks would sometimes be six months. About two and a half years ago she suffered so much from gastric disturbance that she underwent lavage for some time at the hands of a specialist. Another stomach specialist advised her to eat much fat. A

surgeon had told her that she could not have gall-stones because she did not have jaundice, wherein he assumed to disagree with a general practitionr who had been in the case. Later, two years ago, she had the gall-bladder drained by another surgeon and gall-stones were removed. The drainage canal had not closed at the end of a year. The fistulous tract had then been dissected out and the wound was closed, but it did not remain so. Another surgeon operated upon the rectum and curetted the uterus "to cure her indigestion." He repeatedly cauterized the fistuious tract leading into the gall-bladder and applied X-ray and massage to the epigastric region. When she first came to me, Oct. 18th, 1904, the fistula had been closed for six weeks; she was having attacks of severe colicky pain every day or two, but without nausea. Her temperature ranged from 99. to 102. She was sent to the hospital and shortly afterward has a severe chill. On Oct. 22nd, I made an incision which disclosed the gall-bladder, gangrenous in patches and filled with pus; its walls were greatly thickened. The head of the pancreas was four times its normal thickness and harder than normal. Considering the pancreatitis, the indication was to use the gall-bladder as a drainage-tract, but on account of its gangrenous condition I performed cholecystectomy, sewing a drainage-tube over the end of the cystic duct without ligating the duct itself. Her highest temperature subsequent to operation was 100.6. On Nov. 19th, she left the hospital with the wound healed. On Nov. 26th, she again complained of severe pain and for about two weeks was again under observation, although there was no reopening of the wound. On May 15th, at a casual meeting, the patient reported that after the middle of December she had had occasional discomfort in the region of the stomach and gallbladder, but for some time past has been comfortable; and she appears well.

Shortly after the operation upon this patient, a specimen of urine was sent to the Detroit Clinical Laboratory to be tested by the method published recently by Cammidge, working with and indorsed by Mayo Robson. The method is claimed to detect the glycerine thrown into the urine as a result of the metabolic change induced by altered pancreatic function. In our case it was rather a test of the method than a means of diagnosis, but it is of interest to note that the report was positive.

Case XVII. Fecal fistula. Sponge in the abdomen. (Dec. 8th, 2:45 to 4:30 P. M.)

Miss C., aet. 28. Maternal grandmother died of cancer of the breast. Menstruation began at 14; duration one week; regular; dysmenorrhoea, with great suffering the first day. Profuse leucorrhoea for last five years. Had pneumonia two years ago; fully recovered. In June last, another surgeon performed ventrosuspension to relieve retroversio uteri. The incision apparently healed but on the 13th day following the operation a fecal fistula appeared in the median line 15. cm. above the symphysis pubis. Besides the annoyance of this fistula, patient is How suffering from backache, pain in right ovarian region, and nausea after eating. A median incision is now (Dec. 8th) made through the abdominal wall above the fistula; abdominal contents protected by towels; and incision extended downward around both sides of fistulous tract. Intestinal coils and omentum were found adherent to abdominal wall about region of fistula. When these adhesions were separated, a gauze sponge was found lying in the center of the mass. Against the under side of the sponge, lay the caecum and ileum. Somewhat above the ileocaecal valve was a circular opening into the colon 4. cm. in diameter. There was also an opening in the ileum near its caecal junction. The sponge was already partly in the colon and might soon have been discharged per rectum. The openings into the intestines were repaired, with celluloid linen, the line of suture being transverse to the long diameter of the bowel. The mass of infected omentum and the cicatricial tissue in the abdominal wall were dissected away. Examination of the pelvic contents was then made. The peritoneal band formed in the effort to suspend the uterus had been stretched into a mere thread and gave no support. The right ovary was changed into a cyst of the size of a hen's egg. The left ovary contained a cyst of the size of a cherry. The right ovary was removed; the cyst was removed from the left; the uterus was suspended by a shortening of the round ligaments by the method described by Gilliam, of Columbus, Ohio; and the abdominal wound was closed.

On the 6th day, the temperature rose to 101.6 and pulse to 100., when pus was found in the lower angle of the abdominal wound; infection,