realization by the family physician that he has a manifest duty to these cases and that duty is to refer them to the surgeon at the beginning instead of the end of the case.

Otherwise he must prepare to plead guilty to the charge of having not done for his patient the best that can be done for him, and which he certainly had the right to expect and even to demand at his hands.

REPORT OF A CASE IN INTESTINAL ANASTOMOSIS.

J. R. STUART, M. D.,
HOUSTON, TEXAS.

Mr. M., white, male, age 30 years, came to this institution February 20, 1902, with the following history: Had suffered more or less with constipation since infancy and had had rectal discharges of blood at intervals since the same time. One year previous to date, he suffered from an attack of typhoid fever, of the ordinary type, complicated by bloody stools. The present attack of obstipation began one week previous to his entrance. One day, prior to entrance, he began to have fecal vomit. His pulse, upon examination, was regular and temperature normal; and his abdomen very tympanic. An incision into the abdominal cavity revealed the following:

The illium was very much distended and deeply conjested. About midway of the small intestines, a portion of the bowel, approximately four inches in length, had become cartilaginous and the lumen of the bowel in this locality had become, consequently, completely obliterated, not even allowing the passage of gas. The bowel below contained neither fecal matter nor gas. The cicatrical part of the bowel referred to had such a short mesentery as to prevent the bowel being brought up to the incision. On this account, no effort was made to remove the portion of the bowel in question, but the bowel, on each side, was brought up and an opening made in each portion and the two carefully sutured with mattress sutures. The patient rallied readily from the operation, and the next morning had a free movement of the bowels, the first in eight days. On the fifth day after the operation a stitch abscess formed in the lower portion of the wound which, however, healed in a few days. On the ninth day, from the date of the operation, he developed a case of pneumonia, in the lower posterior lobe of the right lung. This complication lasted one week only, since which time he has

made an uninterrupted recovery, and at the present time is perfectly well.

The points of interest in this case are the extent of cicatrization of the bowel and the abnormal length of time of existence, without having produced earlier or more pronounced symptoms. The unusual necessity for making the lateral, rather than the end to end, anastomosis.

Finally, we think the patient is to be congratulated, considering the hurried preparations for operation and the length of time of his attack, upon the fact that he is still in the land of the living.

The physicians concerned in this operation were Drs. Wood, Urwitz, Red, Stuart, Ford and the writer.

REPORT OF TWO INTERESTING CASES OF BRAIN

INJURY.

F. B. SHIELDS, M. D.,

VICTORIA, TEXAS.

M. C., Mexican, age 79 years. Assaulted on the night of November 2nd with the butt end of a shotgun and a club, receiving thereby a compound, comminuted, complicated depressed fracture, involving portions of the frontal, parietal, temporal and occipital bones.

Beginning at hair line directly above the inner canthus of right eye, the fracture extended backward parallel to the suggital suture, to and into the occipital bone, curving downward and forward toward the mastoid process; forward from this point the fissure reached within one inch of the external angular process of the frontal bone, from thence its point of origin was gained. Within this space (7x31 inches in extent) the skull was comminuted and depressed.

When patient arrived at the Valley View Hospital the classical symptoms of compression were present. Operation took place some four hours from time of injury.

Horseshoe scalp incision was made, De Vilbiss trephine and ronguer forceps were employed, fractured bone removed, two large branches of temporal ligated, immense clots were removed from the unruptured dura, wound thoroughly irrigated with warm sterile water, gauze drain inserted, scalp sutured with silk-worm gut, and the almost moribund patient removed to the adjoining surgical ward, where two litres deci-normal salt solution were given per rectum, 250 c. c. subcutaneously, besides other suitable stimulants.

Five hours later nurse reported bandages dyed crimson. In view of the fact that our patient had not yet rallied from shock, reopening of the wound was decided against, and instead a compress was placed over the anterior branch of temporal artery, over this a tourniquet, by which means hemorrhage was quickly controlled.

Patient began to revive under heroic doses of strychnine, atropine, nitro-glycerine, etc. Left-sided hemiphlegia was now discovered.

General condition gradually improved until the third day, when cerebral vomiting and pulse, incontinence of urine and fæces, stertorous respiration, dilated pupils, cold, clammy sweats, presented. Dressings removed, also several sutures and enormous clots-dura still apeared normal.

Fifth day temperature began to rise, and upon removal of dressings, necrosis of the scalp and edges of fracture was to be seen. The necrotic spots in the scalp were mopped with a strong silver solution; the bone was trimmed by means of the rongeur.

Patient began to grow comatose, pupils dilated widely, respiration very shallow, radial artery, pulse less, muscles of deglutition became paralyzed, rectum refused to retain nourishment, and in this condition the old fellow remained eighteen hours despite the most powerful of stimulants.

Toward morning of the seventh day the color began to steal over our patient's face, the radial pulse again became perceptible, drachm doses of milk could be swallowed.

Eighth day, upon removal of the dressings, the dura was found boggy and bulging, into which an incision was made, evacuating some four or five ounces of straw-colored fluid; gauze drain inserted redressed.

Sac full again by the tenth day; scalp necrosis spreading very rapidly, denuding the skull in some six or eight spots the size of a half-dollar. Wild and furious delirium set in, rectal temperature 102, 103 and 104, pulse 140-160, face flushed, eyes bright and glittering. Restraint now became necessary as patient would savagely tear the bandages and gouge his fingers into the wound. Handcuffs and ropes were employed; ice bag to brain, and the long list of hypnotics failed to sooth. Nothing short of restraint would suffice.

The wrists, from being constantly twisted and wrenched, fell heir to periosteal abscesses, which necessitated incising and curetting. Improvement took place very slowly; mania continued for twenty