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813 A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. Nulla autem est alia pro certo noscendi via, nisi quamplurimas et morbormn at dissectionum historias, tum aliorum, tum proprias collect as habere, et inter so comparare.—MORGAGNI De Sed. et Caug. JKof&., lib. iv. Proœmium. GUY’S HOSPITAL. CASES OF STRANGULATED FEMORAL HERNIA. (Under the care of Mr. JOHN BIRKETT.) THE week rarely passes away, at the larger metropolitan ’’, hospitals, without one or more cases of strangulated hernia requiring to be relieved and reduced by a cutting operation. But it seldom happens that three cases of so much interest, and affording such sound practical lessons, occur within the period of a few hours as those related below. On the 6th and 7th of last February the cases were admitted, and all of them have been fully reported by Mr. W. E. Saunders. We shall briefly call attention to their chief characteristics, and then record their most striking features. The first case is most remarkable as a recovery after fifteen days’ continued vomiting. The accuracy of this fact may be relied upon as Mr. Birkett took especial pains to discover if any erroneous statement was made, by inquiring of more than one individual, and upon several occasions. The prostration was such, when admitted, that life seemed nearly extinct; and it was several days before there appeared to be a hope of saving the patfent. The state of the protruded bowel deserves particular attention, as affording an illustration of the condi- tion of the viscus as affected by the constriction produced by the orifice of the sac and the tissues surrounding it alone, and not injured by manipulation, for attempts had never been made to reduce it by taxis. The second case affords a striking example of the happy termination of a case of strangulated hernia when early divi- sion of the impediments to its reduction is accomplished with- out opening the hernial sac ; and especially in a case of the kind here related, in which certain conditions of the tumour preclude the effectual application of the taxis. The last case is an instance of the results of delaying the liberation of the bowel by a cutting operation until the injured bowel has sloughed, and it passes back into the peritoneal cavity, there to produce fatal mischief by allowing the escape of its contents within it. CASE 1. Vomiting for fifteen days adhesion of the bowel to the sac,’ great prostration; cure. - A thin, small, delicate, married woman, forty-two years old, was admitted on account of a strangulated right femoral hernia, which had been ob- served for two or three months. She had never worn a truss. She was suckling an infant born eight months since. On ad- mission she had been vomiting for fifteen days. The surface of the body was cold; the extremities and face blue; the pulse was just perceptible; she could scarcely articulate; the tongue dry and red; the abdomen tympanitic. There was a small tumour in the right groin. Although the patient had been visited by a medical man, no attempt was made to return the rupture. Mr. Birkett proceeded to reduce the bowel soon after admission. The patient was placed under chloroform, and an oblique incision was made along the upper and inner border of the tumour. The hernial sac and bowel were firmly united together, and great caution was required to avoid injuring the latter, although its thickened, leathery texture almost pre- ,,cludecl the chance of doing sj. The orifice of the sac was very small, and required division. Having with difficulty reduced the protruded intestine on account of the firm adhesions, the wound was dressed with lint and plaster. Opium and stimuli were cautiously administered, and milk diet. Improvement in the general condition was remarkably slow; but on the fourth day after the operation she asked for some solid food, "because she felt so hungry." " A little finely-cut chicken on bread was given her, which she enjoyed. In spite of extensive suppuration about the wound, retention of urine, great intes- tinal tympanitis, a little diarrhoea., a small bedore, a severe attack of articular rheumatism after the wound was healed, she left the hospital well. CASE 2. Vomiting nineteen hours; reduction of the her-nia without opening the sac; speedy recovery.-A healthy, married, prolitic woman, aged forty-four years, had observed a right femoral rupture for about a yeas. She had never worn a truss. It frequently caused inconvenience by its descent, but went back after lying down. The day before admission she had felt more pain in the groin than usual, the tumour was larger, and she could not push it back. Nineteen hours before Mr. Birkett saw her she began to vomit. The femoral tumour was of moderate size, very movable, and the tissues covering it were healthy. Taxis had not been employed. The patient was placed under the influence of chloroform; and Mr. Birkett tried to reduce the rupture by pressure. He failed, however, to do so; and then incised the integuments covering the fascia propria. Having now reached Gimbernat’s ligament, he in- troduced the hernia bistoury, on the tip of the finger, beneath that structure, which was divided sufficiently only to enable him to reduce the protruded bowel by gentle pressure. This being effected, the wound was dressed with sutures, lint, and plaster. The tissues around the orifice and neck of the sac were very tight and firm; and, from the flask-shaped form of the sac and the great mobility of the tumour, Mr. Birkett attributed the impossibility of reducing the rupture without a cutting operation. This patient recovered without an unto- ward symptom, and left the hospital well in a month, wearing a truss. CASE 3. Vomiting four and a half days bowel sloughed and returned into the abdomen ; sac incised and tissues sloughing; / death.-A large, fat, bronchitic, married woman, fifty-eight years old, had been the subject of a left femoral rupture for about eight months. She had never worn a truss. For several days before admission there had been a tumour, larger than usual, in the groin; and she had vomited constantly for four days and a half. She was admitted in a dying state. The integuments over and about the tumour were of a dusky-red colour and cedematous. When an incision had been made through them, sero-purulent effusion flowed out. Mr. Birkett was unable to distinguish one structure from another, and that which seemed to be the peritoneal sac contained pus and fecu- lent fluid. The hernia had been reduced. The patient sur- vived this operation a few hours. Recourse to surgical assist- ance had been neglected until vomiting commenced, after which attempts to return the protrusion had been frequently made before admission. By after-death examination the por- tion of small intestine which had been in the sac was seen to have sloughed and burst, although very little extravasation of the contents of the tube had taken place, and there was very slight peritonitis. The protruded bowel had been a portion of the upper part of the canal, about seven feet and a half below the duodenum-rather unusually high. Neither the pleuræ, lungs, heart, kidneys, nor liver were healthy. LONDON HOSPITAL. SEQUEL TO A CASE OF SYPHILITIC PARALYSIS; DEATH; AUTOPSY. (Under the care of Dr. RAMSKILL.) THE patient, whose case we briefly recorded in the "Mirror" of March 28th, died on June 7th. There is little of importance to add to that record. For the following facts we are indebted to Mr. George W. Mackenzie. Towards the end of April the patient’s right optic disc was found to be swollen; veins large and irregular, and pai tly obscured; disc raised, reddish white. bright, and smoothed off into fundus ; arteries large, and easily traceable; left disc only hastily caught; veins large, and appearances believed to be those of the right disc. From this time he became gradually worse, and mostly passed his motions and urine in bed. A few days before his death it was obvious that he did not move his left arm and leg so well as the right, but could move them a little when they were pinched. Autopsy.-As 1).a(l leen diagnosed by Dr. PLamskill from the first, the cause of the patient’s symptoms was clearly syphilis. There were in the hemispheres, or rather in the pia mater over them. one or two small nodules, of a yellowish colour and tough consistence ; there were also one or two on the tentorium cerebelli, and also in the left middle fossa of the skull, around the ganglion of the fifth pair of nerves. But the
