489

accompanied by general pyrexia. Dry cupping, warm bath,and diaphoretic mixture were ordered. The patient again im-proved, the urine lost the appearance of blood, but it containedalbumen. Relapses, however, occurred, the symptoms denotingrenal haemorrhage, apparently of a passive kind. Astringents,in the form of diacetate of lead and opium, gallic acid, and thetincture of the sesquichloride of iron, were prescribed on thedifferent occasions, each with apparent advantage.On March 3rd the symptoms of the patient assumed a typhoid

character. They were as follows :-Delirium at night ; dryand brown tongue; diarrhœa,; small, frequent pulse ; rigorsand occasional sweatings ; throbbing pain across the kidneys ;great frontal headache ; intense thirst ; great prostration ; apeculiar earthy, yellow discoloration of the skin. A few

papules, the nature of which was doubtful, were observed uponthe abdomen and thorax. The urine on this day was red andturbid, normal in quantity, and of high specific gravity. The

patient was ordered carbonate of ammonia, and twelve ouncesof wine. A few days after the above symptoms made theirappearance, a deposit was observed in the urine, which, onmicroscopical and chemical examinations, was found to be pus.Under the above stimulating treatment the patient gradually

became convalescent, so that by the end of March he wasallowed to leave his bed, was put on meat diet, and ordered totake quinine. The pus gradually disappeared from the urine.The register of March 31st contains the following :-Urinetwo quarts, clear, bright-straw colour ; specific gravity 1020 ;the slightest cloudiness on heating and adding nitric acid.

ST. GEORGE’S HOSPITAL.MALIGNANT DISEASE OF THE LUNG; DISEASED KIDNEYS;

DEATH.

(Under the care of Dr. PAGE.)ANGFLI.BT-A. S-, aged fifty-one, was admitted April 10th,

1861. She had a pasty complexion and a bloated aspect, andstated that she had been in good health until six weeks beforeadmission, when she began to experience cough with muchexpectoration ; this had been so severe during the last fortnightas to compel her to keep her bed. When she came under ob-servation she had frequent cough with copious expectoration,and ortbopncea. The right breast, and the left to a less extent,the right arm and side of the head, wera turgid with blood andswollen. The posterior portions of the right lung were dull onpercussion, and the vocal fremitus was greater there than onthe left side. She was at once ordered to take one-third of agrain of potassio-tartrate of antimony in camphor mixture everysix hours, in the belief that the consolidation of the right lungwas pneumonia. This at first made her sick. Next day somenitric ether was ad,led, and four ounces of gin given. Whenthe urine was examined, it was found to contain albumen.She now complained of much pain in the right side of the

chpst. There was deficiency of breathing in front, as well aslack of resonance behind ; and the liver appeared to berather prominent. The pain was much relieved by a blister.One grain of calomel, a quarter of a grain of tartar emetic, anda quarter of a grain of opium, were ordered every six hours;these made her somewhat drowsy and stupid.On the 20th the face was much swollen. She had occasion-

ally attaclis of dyspncea, with much blueness of the countenance.These were generally relieved by ether. She still continuedto take antimonial remedies, and at the same time wine or gin,as suited her ; and she generally had a morphia draught atnight.On the night of the 28th, after having been walking about

the ward, she retired to bed, and went to sleep comfortably; buttowards the morning she woke up in great distress fromdyspnoea., with much blueness of the face, and she died appa-rently of want of breath.Autopsy thirty-two hours after death.-The body was very

fat. There was a large quantity of serous fluid in the peri-cardium. The heart was soft and thin ; its valves healthy. Theleft lung and pleura were healthy. A large malignant tumour,of soft consistence, and yielding an abundant juice on pressure,occupied the posterior mediastinum and the lower part of theright lung, extending also into the anterior mediastinum.Numerous bronchial glands were found lying ing loose and movableon the principal tumour. There were a large number of oldperitoneal adhesions around the liver, which was healthy instructure. The gall-bladder contained a single large oval gall-

stone. The bile-duct was of very large size, and pervious. The

kidneys were small, weighing together seven ounces and three-quarters ; their capsules were adherent, and surface granular,with numerous small fibrinous deposits. Supra renal glands.and spleen were healthy. The uterus contained numeroussmall, interstitial, fibrinous tumours ; the ovaries were healthy-

GUY’S HOSPITAL.

CLINICAL REMARKS ON TWO CASIS OF LACERATION OF

THE PERINEUM THROUGH THE SPHINCTER

AND RECTO-VAGINAL SEPTUM.

IN a late number of this journal we gave two successful cases.of vesico-vaginal fistula, in both of which recovery followed theoperation as peaformed by Mr. Bryant. We now record two.others of a different nature, the perineum and rectum being the-parts involved in the laceration, the fissure in both instancesextending through the sphincter, causing complete inability toretain the faeces. In both, the operative measures adopted.were followed by complete success.

LACERATION OF THE PERINEUM INTO THE RECTUM.

(Under the care of Dr. OLDHAM and Mr. THOMAS BRYANT.)The notes of the following cases were reported by Dr..

Morris :-Ann B-, aged forty-one, was admitted into the above

hospital on the Ilth of April, 1861. She was a healthy mar-ried woman, who had given birth to four children, the firstand two last of which had been delivered by means of instru-ments. The last confinement took place in November, 18-58,and it was at that date that she received the injury for whichshe was admitted.On making an examination of the parts, an extensive lacera-

tion of the perineum was readily detected, which passed back--wards through the sphincter into the rectum, producing com-plete inability to control the passage of the faeces.On April 12th Mr. Bryant operated upon the patient, freely

paring the edges of the fissure, together with the margin ofthe recto-vaginal septum; a deep suture was then passedthrough the septum and perineum, and, with two others passedabove the edges, were kept together by means of the quiilsuture.On April 16th, or fourth day after the operation, the parts

appeared to be sloughing, and the quills to be pressing severelyupon the œdematous tissues; the sutures were consequentlyremoved, no union having taken place.On April 18th, or sixth day, the parts bad regained their

natural condition, and, as the granulations were all healthy,Mr. Bryant re-a,dapted the.two surfaces, and fixed them by twosilk sutures; these were kept in for two weeks, when com-plete union had taken place.The patient was subsequently well able to retain her faeces,

’ and to control the action of the bowels. She left the hospital,.’ cured, on June 4th.

LACERATION OF THE PERINEUM, EXTENDING INTO THE RECTUM.

(Under the care of Dr. BRAXTON HICKS and Mr. BRYANT.)

Mary A. S-, aged twenty-one, was admitted into Maryward on May 9th, 1860. In October last she was delivered of herfirst child by means of instruments, producing a laceration ofthe perineum, extending through the sphincter into the rectum,and when admitted she was quite unable to restrain or to con-trol the action of the bowels.

In December, 1859, and March, 1860, Elie had been operated-upon, but withont success.On May 9th, Mr. Bryant freely pared the edges of the fissure

together with the margin of the recto-vaginal septum. He thenbrought the edges closely together by means of wire sutures,passing the back one through the septum, and introducing thesutures at least one inch from the margin of the wound. Atthe expiration of one week, perfect union having apparentlytaken place, the wires were removed ; control also of the

sphincter had been regained.On March 26th, it was discovered that a small portion of

fseces came through the vagina, a minute opening existingabove the external sphincter. ’l his, however, was granulating,being situated at the upper portion of the wound. The bowelswere therefore kept at rest by the free administration of opiumfor four days, when the fistula had closed, the woman leavingthe hospital quite well.