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CASE 4. S’trangulated crural hania: herniotomy; sac opened /n diverticulum running down front of thigh; death.-A womanaged forty-seven was admitted into Bird ward on July 7th,186G, with a strangulated crural hernia. An oblong swellingreached along the left groin from the pubes nearly to the ante-rior superior iliac spine. It was very tense, and irreducibleby taxis. The granular feel of its contents showed that thesewere, in part, evidently omental. Pulse 84, very weak. Ex-pression calm, but she says she suffers great pain at thenavel. She had been ruptured many years, and said that therupture had always been perfectly reducible by herself untilfour days before, when it protruded, and she could not pressit back as formerly. It immediately became extremely pain-ful ; the pain extended upwards from it to the navel, and shesoon began to retch. On the fourth day she was seen by asurgeon, who sent her from Potter’s Bar to the hospital, aftertrying to reduce it. A second attempt was made in the hotbath by the house-surgeon, and this also failing, Mr. Hulkesaw the patient, and immediately operated. The tissues out-side the sac were red and codematous. On opening the sac,two drachms of bloody serum ran out, and a piece of oedema-tous omentum came into view ; behind this, a loop of darkclaret-coloured gut was found upon the posterior wall of thesac, through a hole in which it passed into a diverticulumrunning down the front of the thigh. The bowel was fixed tothe posterior margin of this hole by a firm old adhesion. Whenthis was separated, another obstacle to reduction was found ina thin cord of omentum stretching across the loop of gut atthe internal aperture of the crural canal. After this was cut,the gut and omentum were easily replaced in the belly. Thelower end of the wound was left open for the escape of dis-charge, and a very light compress was applied. The retchingcontinued until twelve o’clock P.M. At five A.M. collapse setin, and she shortly died, about twelve hours after the opera-tion.On examination after death, the peritoneum was found to be

throughout its whole extent coated with puriform lymph. A

large ascaris lumbricoides was discovered free in the peritonealcavity, and a small quantity of fluid faecal matter had trickleddown into the pelvis. The great omentum was gathered, fan-like, to the internal aperture of the crural canal, to which itfirmly adhered; here it was of a deep purple colour, andthickened. The bowel which had been strangulated lay alsonear the internal crural ring; it was almost black, and markedby a deep circular indentation below, and a somewhat lessmarked one above. At the bottom of the deeper constrictionthere was a very narrow ulcer with thickened edges involvingabout a third of the circumference of the gut, and at its centrea small circular perforation through all the coats. A largesubperitoneal space was found extending downwards from theinner end of the crural canal over the obturator foramen, andinwards behind the pubic symphysis. It seemed to have beenproduced by the peritoneum having been pushed off the pelvicwalls during the patient’s indiscriminate efforts to reduce the?upture.

HOSPITAL OUT-PATIENT PRACTICE.

MENORRHAGIA.IN the ordinary practice of everyday life there are few con

ditions which the medical attendant is more often consultedabout than those of which menorrhagia is a symptom. Or

rather, perhaps (and here lies a great source of fallacy), he isconsulted about the menorrhagia so often that he is led inmany instances to look upon this symptom as a specific dis-order which will yield to specific remedies. And so, in thatardent yearning after knowledge which is so often seen for thefirst time in a newly-fledged medical man who has just ceasedto be a student, the question will be frequently asked, " Whatis a good thing for menorrhagia?" as who should say, "How Ido you cure the headache ?" In referring to the subject herewe do not of course suppose that our readers are likely to fallinto a similar error, but we have collected from some of thehospitals a few hints respecting the treatment of the differentpathological conditions of which this symptom is so frequently lan exponent, and these will probably be interesting as well as !useful,

ST. BARTHOLOMEW’S HOSPITAL.Dr. Greenhalgh remarks that in the treatment of this symp-

tom (menorrhagia.)—due to such a variety of causes, among

which may be enumerated fibroid and fibrous tumours of theuterus, non-pedunculated and pedunculated; subinvolution,congestion, altered conditions of its mucous lining, nbrinousclots and other abnormal contents, malpositions, spongoidtumours of the cervix, malignant diseases, &c., occurringunder such variable and widely differing circumstances, andvarying so much in duration and intensity, and in its effects inindividual cases-considerable modifications must of necessitybe and are pursued; still, for the sake of dispatch and facilityin dispensing, a certain routine is observed in the out-patientfemale department which will sufficiently indicate the usualcourse of treatment adopted by him in this institution. Byfar the greater number of cases of menorrhagia are due tofibroid or fibrous out-growths or in-growths from the uterus,which are mostly treated by a pill composed of one-twelfth ofa grain of bichloride of mercury combined with quinine andbelladonna, to which is frequently added small quantities ofthe aqueous extract of aloes, taken night and morning forsome weeks ; a mixture composed of dilute sulphuric acid,tincture of Indian hemp, mucilage, liquid extract of ergot,syrup, and infusion of quassia, three or four times a day, beingordered just prior to and during the catamenial flow. Betweenthe "periods" a draught of iodide or bromide of potass, withthe liquid extract of ergot, sal volatile, and infusion of quassia,is given twice a day. If the loss of blood have been verygreat, or the patient be anaemic, the tincture of sesquichlorideof iron with the liquid extract of ergot, chloric ether, syrup,and infusion of quassia, twice or thrice a day, with the pills,are prescribed. Where the patient is more or less plethoric,which is rarely the case, the sulphate of magnesia and digitalis,either with dilute sulphuric acid or salines, and scarificationsor leechings of the cervix uteri, are found most serviceable.In cases of subinvolution of the uterus, attended with menor-rhagia due to imperfect recovery from labour or miscarriage,hyperlactation, or other affections leading to constitutional de-bility, especially in the strumous habit, the syrup of the iodideof iron with or without ergot, and with the pill above referredto, are found very efficacious. A similar course is pursued,sometimes with, sometimes without, the pills, where the com-mencement of malignant disease is the exciting cause of thissymptom.In cases of Bright’s disease and other affections interfering

with the stasis of the blood, gallic or tannic acid, usually com-bined with henbane, prove valuable hæmostatics ; some pre-paration of iron with arsenic being usually ordered betweenthe "periods." Where polypi, portions of retained ovum, or

fibrinous clots are detected, they are removed.Dr. Greenhalgh particularly draws attention to the frequency

of menorrhagia as the result of collections of fecal matter inthe large intestines and rectum, and of hepatic derangementsoccasioning mechanical irritation and congestions of the hamior-rhoidal vessels and uterus. For calculi, in addition to thepills, he prescribes repeated doses of the compound decoctionof aloes, with tincture of nux vomica.

In all cases he recommends quiet of mind and body; rest inthe recumbent posture; nutritious and unstimulating diet;cold acid drinks; tepid or cold water vaginal injections; greatmoderation or total abstinence from sexual excitement.He now and then has recourse to the following means:-

Matico-cotton plugs or pessaries; astringent vaginal injec-tions ; sponge tents; iodide of lead and atropine pessaries;iodised cotton; Hodge’s and other pessaries in cases of mis-placements of the uterus, &c.

Dr. Greenhalgh adds that, cœteris paribus, menorrhagia ismore prevalent among women of lax fibre, more especially ifthey have had many children or abortions in rapid succession;in those subject to acne, pruritus, or eczema, and about the cli-macteric ; in those of intemperate habits of various kinds, &c.He considers it is by no means always easy to determine

whether the case is one of menorrhagia or threatened abortion,I _

i UNIVERSITY COLLEGE HOSPITAL.Cases of menorrhagia pure and simple, and apart from the

presence of some physical alteration of the uterus, are, accord-ing to Dr. Graily Hewitt’s experience, very rare; and he haslittle belief in the efficacy of specifics for the cure of this

symptom. The condition of the uterus causing the undueloss must be treated, whether it be flexion, polypus, com-

mencing carcinoma, &c., in order to procure satisfactory results.In all cases Dr. Hewitt attaches much importance to rest

during the " period. Daily use of the vaginal douche of coldwater is a valuable means of diminishing the congestion andrestoring the lost tonicity of the uterus. The tincture of iron,

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in doses of from fifteen to twenty minims three times a day,combined with a few drops of glycerine, is very frequentlygiven, and found efficacious, where the system is debilitatedfrom repeated losses of blood. In many cases Dr. Hewittadministers a few doses of ergot in powder (half a drachmthree times a day).The point to which the greatest attention is directed is the

procuring an exact diagnosis of the state of the uterus. Ob-stinate menorrhagia is often, Dr. Hewitt says, found to be dueto some physical alteration of the uterus, overlooked and con-sequently not treated. Of the latter class of cases, retroflexionof the uterus is a most marked instance.

GREAT NORTHERN HOSPITAL.

For the last few years Dr. Murray has treated cases ofmenorrhagia-not dependent upon growths, displacements,or other causes requiring special and manipulative inter-ference-by the combined use of gallic and sulphuric acidsprincipally, with as much rest as can be obtained. The dis-ease has generally shown itself in one of the three followingforms :-1. Where at each period there has been a more decidedloss than natural. 2. Where, from excessive debility, a bloodydischarge has continued from month to month. 3. Where,after childbearing, a large uterus with a patulous os is con-tinually pouring out blood, and every now and then doing soin gushes accompanied by clots. In all these degrees of thistroublesome and weakening complaint, Dr. Murray is in thehabit of prescribing from five to ten grains of gallic acid withfrom fifteen to twenty-five minims of dilute sulphuric acid,twice or thrice daily, for a period sometimes extending overtwo months. Occasionally he has found the use of mustardapplied over the sacrum every other night, or even a blisteron the same spot, useful as a help in the third form of thishaemorrhage. He has also advised the application of coldwater to the lower part of the spine in cases of continued dis-nha.rcff’ (not lpiieorrh(pnl) between thf neriortf1.As a rule, the patients, after taking the acid mixture for a

few days or a week, notice a decided change for the better.The discharge may then reappear almost as much as before,but it is only for a day or two; and the result after a moderatecourse of these acids has been for the most part beneficial, andin many cases quite satisfactory.

Dr. Murray has.not found the use of iron at all satisfactory;but he has administered it with good effect in some cases aftera continuance of the acid mixture, and all arrest of haemorrhagefor some time. The use of vaginal injections has not been re-commended by Dr. Murray ; but in many cases cold-water

, enemata have been extremely useful at those moments whenthe gushes of blood with clots take place, a gentle non-irritatingpurgative being also given.

CHARING-CROSS HOSPITAL.

Dr. Parson iinds that there are scarcely any two cases ofmenorrhagia that can be treated alike ; that there is virtuallyno line of treatment applicable to all cases ; and that success

generally depends on the accuracy of the diagnosis of the iznvze-diccte or remote causes. He does not consider menorrhagia tobe a disease per sf, but only a prominent symptom of one ormore of the following states, which are exceedingly common:-Menorrhagia is one of the symptoms of metritis; of a gra- I

nular condition of the mucous membrane of the cervix uteri;of polypi of the uterus ; of mucous polypi of the cervix uteri;of fibroid tumours of the uterus ; and of cancers of the uterus,&c. ;-local conditions, some of which are benefited by localtreatment, others not so.Menorrhagia is frequently a symptom of some diseases re-

mote from the generative system ; and these, being unattendedby any local lesions in the uterus or its appendages, are notusually benefited by any local treatment-such as the menor-rhagia of general debility after suckling, or the menorrhagiaresulting from congestion of the portal system, or in cases ofcongestion of the whole venous system in consequence of mitralor aortic obstruction ; or of emphysema and chronic bronchitisinducing a similarly distended state of the veins, or as a con-sequence of kidney-disease and albuminuria, and in some casesof scorbutic nature. In these the treatment is Wl/em1, andnot local.

Rest, as much as possible, is recommended in all cases ofmenorrhagia ; and the avoidance of household duties, at leastfor a few days, during the severity of the symptoms.The astringent mixture in general use amongst the out-

patients consists of tannic acid (from five to ten grains), dilute

sulphuric acid (from twenty to thirty minims), and the liquidextract of ergot of the British Pharmacopoeia (from five to tenminims), every four or five hours for the first few days. Ifthere be much pain attending the menorrhagia, Dr. Parsonusually orders from five to ten minims of the tincture ofIndian hemp to each dose. Dr. Parson has never seen anv illresult following the use of the Indian hemp, but he hasgenerally employed it in the former combination, or with otherastringents.

As a general rule, all the preparations of iron are avoided illmenorrhagia, even though there be anaemia, and pallor, sinceiron invariably increases the vascularity of the pelvic organs ; -.and he employs the preparations of iron only when two orthree menstrual periods have been passed normally.

Aloes also is avoided, in most of its preparations, in all casesof menorrhagia, since it is apt to increase the irritability andvascularity of the pelvic viscera.

Menorrhagia associated with metritis is treated byastrin-gents for the first few days. The bowels are regulated by asaline aperient-the bitartrate of potash in drachm doses, withquinine in half to one grain doses, taken every morning. Afterthe period has ceased the usual treatment of metritis is em-rtlnvp.f!.

Menorrhagia, associated with a granular state of the mucousmembrane of the cervix uteri is treated by astringents andtonics generally. A local astringent consisting of the solutionof chloride of zinc (Burnett’s), from twenty to thirty minimsto every pint of water, is also used by the patient two or threetimes a day as a douche. Dr. Parson finds that a strongerastringent than this for local application is seldom, if ever,required in these cases.The cases of menorrhagia associated with polypi are not

treated with any benefit as out-patients, but are admitted asin-patients of the hospital.

Cases of menorrhagia resulting from the presence of fibroidtumours of the uterus are treated usually as in-patients also.

Menorrhagia arising from cancer of the uterus usually resistsall treatment. From twenty to thirty minims of solution ofchloride of zinc to a pint of water often is more useful thanany other douche in diminishing the fetor, and to some extentthe amount of the discharges.In the following cases of menorrhagia, where there are no

local lesions of the generative organs, a brief summary of thetreatment is as follows :-From debility, it is treated by astringents during the period;

after the period has ceased tonics are employed, excluding ironand aloes until the tendency to excessive menstruation hasceased, then the preparation of iron with nux vomica or strych-nine become valuable.When depending on congestion of the portal system, it is

relieved by a daily aperient of bitartrate of potash with quinine,and with or without five to ten grains of jalap in each dose,taken every morning, and avoidance of alcoholic stimulants.

Associated with mitral or aortic obstruction, menorrhagia ismost difficult to relieve, and is treated on general principles-of diminishing the congestion of the pelvic organs as much aspossible, and giving tone to the distended capillaries and veins.

Menorrhagia with emphysema or chronic bronchitis is alsoexceedingly difficult to relieve, and when relieved for a time,often returns.

Resulting from kidney-disease and albuminuria, it is treatedby warm clothing; aperients daily of compound jalap powderwith quinine, given in the mornings, and the sesquichloride ofiron with nux vomica two or three times a day, generally withmarked improvement.When associated with spongy gums and a scorbutic state, it

is treated by the citrate and chlorate of potash; the patientbeing directed to avoid all salted meat; to take the juice of

7

half a lemon every day; occasionally tannic acid is given inaddition.

MIDLAND MEDICAL SOCIETY, BIRMINGHAM.—At ameeting held on the 10th ult., Mr. J. S. Gamgee in the chair,Dr. Wylie exhibited a pancreas containing several cysts ; alarge one, situated in the head of the gland, had burst a fewdays before death, causing fatal peritonitis. No fat had beennoticed in the faeces. Dr. Wylie also exhibited specimens ofcancer of the stomach and liver, and of stricture of the trans-verse colon, associated with a ragged perforation of the caecumand abscess opening through the abdominal wall. Mr. J. S.Gamgee read a paper On Medical Evidence in Actions forDamages after Railway Injuries," in which the subject wastreated in a most able and comprehensive manner. A veryspirited discussion followed.