541

whish had been opened by ulceration. Shortly before deaththe patient had taken bread, toasted cheese, and beer.These cases illustrate the insidious nature of pyloric

cancer, and two methods by which it may end fatally. ’,Longhborough.

_____________ I

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

MIDDLESEX HOSPITAL.CASES OF STRANGULATED HERNIA.

(Under the care of Mr. HULKE.)

Nullaantem est alia pro certo noscendi via, nisi quamplurimas et morborumetdissectionum historias, tum aliorum tum proprias collectas habere, etinter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Prommium. i

THE many variations in their anatomical and pathologicalcircumstances which herniæ offer have ever given to them apeculiar interest. The first of the following cases illustratesa not infrequent complication of the ordinary form of con.genital scrotal rupture-a constriction of the sac at somedistance below the external abdominal ring separating anupper from a lower compartment, the tunica vaginalisenclosing the testis. Such constriction, more than one maybe present, marks a spot where there has been an approachto obliteration of the tube of the funicular process. Its

significance in relation to strangulation is evidenced by thegreater intensity of the congestion &c. usually found in thoseparts of the protruded viscera occupying the sac below it,and also by the resistance it offers to their extrication andreplacement in the belly after their complete liberationfrom constriction at the abdominal rings, an impedimentwhich deceptively simulates that caused by adhesions ofthe viscera to the bottom of the sac or testis. Perhapssuch complications account in some measure for the greatermortality of strangulated congenital ruptures noticed bymore than one writer of eminence. The anatomical circum.stances in the second case nearly resembled those in thefirst. The third case illustrates a very frequent event : thesupervention of hernia upon retention of the testis in theinguinal canal. In the fourth case the inconveniences inci-dental to this error loci, together with the evidentlyimperfectly developed condition of the organ, justified itsremoval, a measure the propriety of which would have beendoubtful had the organ been sufficiently mobile to haveallowed its being drawn down out of the inguinal canal andplanted in the scrotum, or even replaced in the belly. Thefourth case exemplifies one of the. gravest accidents thatcan happen in connexion with a strangulated hernia-its reduction en bloc or en masse, by an improper useof the taxis, not infrequently by the efforts of an un-

skilful patient, who in his anxiety and suffering makesviolent and ill-directed pressure in his attempts to reducethe hernia. After such an accident the surgeon whothen first sees the patient, and is not informed of the

previous circumstances, may, in the absence of an externalhernial swelling, pardonably ascribe the symptoms to aninternal intestinal obstruction. But reduction en bloc mayalso occur in herniotomy where the sac is not opened, and athin shell of fascia or condensed subserous tissue externalto the sac has been mistaken for this latter, in which caseafter liberation of every constriction at the abdominalopenings, the sac still enclosing the protruded viscera mayby injudicious pressure (which need not, however, neces.sarily be great) be detached from its surrounding connexions,and slip up within the belly. This accident (which, oddlyenough, was thought by an eminent author to occur only ininguinal hernia) appears to be more frequent in the femoralvariety. Three instances of this occurred within the writer’sknowledge in the course of one year in the practice of threesurgeons, two of whom had a large experience in herniotomy,and the third one had already operated in several cases.In two of these cases persistence of symptoms caused asuspicion of the accident. The wound was opened up,the unopened sac, with its neck girthing tightly the in-

. testine within it, was found outside the peritoneal cavity,below the pelvic brim brought into view and opened; the

: stricture formed by the neck of the sac was divided, and thegut replaced in the belly, but too late to avert a fatal issue.Of three cases within the writer’s knowledge of reductionen bloc of inguinal hernias by improper taxis, two of thepatients were males; in the other case, the rupture hadhabitually distended the left labium pudendi. The per-sistence of symptoms of obstruction, after an apparentlysuccessful reduction of the rupture, led to an exploration ofthe inguinal canal. The sac was found above the positionof the internal abdominal ring, in a subserous space betweenthe peritoneum and fascia transversalis. It was broughtdown, opened, and the intestine was liberated and reduced,but in this case also the error was recognised too late to savethe patient’s life. The interest of the fifth case lies in theearly time of the operation-one hour after the occurrenceof strangulation. Here, in view of the urgency of thesymptoms, any delay would have been dangerous.CASE 1. Strangulated Congenital Scrotal Rupture; Hour-

glass Contraction of the Sac; Herniotomy; Recovery.—OnJune 12tb, 1882, a cabinet-maker, aged twenty-five, whohad previously occasionally noticed a fulness in his leftgroin, fell whilst running. He instantly felt severe pain inthat region, and had great nausea. He found his scrotumswollen, and soon began to vomit. Two hours after theaccident he was admitted into the hospital. The right in-guinal canal and corresponding side of the scrotum weredistended by a rupture, the scrotal portion of which, by itstenseness and the absence of impulse, was unmistakablystrangulated, but this could not be certainly ascertainedwith respect to the inguinal portion. His suffering wasvery great; he writhed with pain; and he retched frequently.Anmsthesia was induced with ether, and, the taxis failing,herniotomy was at once performed. Reduction proved im-practicable until the sac had been opened, when the obstaclewas found to be a diaphragm-like septum, which subdividedthe scrotal portion into an upper and a lower compartment,the latter of which also contained the testis. Division ofthe edge of the small opening in this septum liberated aknuckle of very congested small intestine, after which re-duction was easily effected. On the 30th of the same monththe man left the hospital convalescent.CASE 2. Strangulated Bubonocele ; Serous Distension of

the Scrotal Parts of the Funicular Process; Herniotomy;Hæmorrhage on the following day necessitating opening upof the Wound; Recovery.-A man, aged twenty-three,received through his horse falling a severe blow in the rightgroin, causing intense pain there. After a few minutes thisabated so that he was able to remount and ride home, butthree hours later it returned with increased intensity and hethen began to vomit. On the following morning he wasfirst seen by a doctor, who recognised the presence of arupture and tried the taxis and ice, and as these measuresfailed he sent the man into hospital. Upon admission,about twenty-four hours after the injury, his right inguinalcanal was found occupied by a very tense, painful, andtender swelling, from which a painless, less tense, fluctuat-ing, oblong process, extended through the external ab-dominal ring into the scrotum. As the symptoms wereacute and the strangulation had already lasted twenty-fourhours, the rupture was immediately submitted to operation.The inguinal parts enclosed a knuckle of small intestineintensely congested. The scrotal part contained only serum.It communicated with the inguinal at the external ring bya circular opening of the size of a No. 10 catheter. Thestrangulation was at the internal abdominal ring external tothe sac. In the following afternoon bmmorrbage occurredso free that the house-surgeon felt compelled to open thewound. The bleeding proceeded from several small arteriesin the scrotal incision; they were secured. The bowelsacted first on the thirteenth day, and on the twenty-thirdday the man was dismissed convalescent. The occurrenceof such haemorrhage is very exceptional.CASE 3. Retained Testis; Strangulated Bubonocele ; Her.

niotomy; Removal of Testis; Peritonitis; Becovery. (Fromnotes by the dresser, Mr. Stace.)—An engineer, agedtwenty-one, whose right testis had not descended into thescrotum, whilst straining in the watercloset suddenly feltpain in his right groin, and placing his hand there found aswelling. Within a few minutes of this occurrence hevomited, and he was sick again later in the day. Sufferingacutely he took two opening pills, and as those did not actand his distress grew greater he was brought next day to the

542

hospital. His right inguinal canal was occupied by an ex-cessively tender, painful swelling, the lower end of whichprotruded slightly through the external abdominal rings.The intensity of the pain in the bt Ily would not let him liestill, but he tossed about restlessly in bed. His face waspale and his pulse quick, small, and weak. There could notbe any doubt that tne swelling was an acutely strangulatedbubonocele. Ether was given, the taxis gently tried for acouple of minutes, and failing, herniotomy was immediatelydone. The sac contained about an ounce and a half of turbidbloody serum and a knuckle of distended, purplish-brownsmall iatestine. The constriction was in the neck of the sac.Behind the gut was the testis, not larger than a small nut,and flabby. As it was evidently imperfectly developed andpresumably functionally useless, and its situation exposed itto violence and would have made difficult the wearing atruss, it was removed. A sharp attack of peritonitis followedthe operation. It was treated with opium internally, bymercurial inunction on the thighs, and the application ofleeches, followed by fomentations to the belly. Coincidentlywith the appearance of slight soreness of the gums the abdo-minal symptoms began to ab ite; they rapidly disappeared,so that by April 6th he had recovered as regarded the hernia,and was about to be dismissed when an attack of pleurisy ’,necessitated his transfer to a medical ward.

’

CASE 4. Strangulated Inguinal Rupture; Reduction enmasse; Herniotomy; Recovery. (From notes taken by thedresser, Mr. G. Cree.)-An engineer, aged fifty-nine, whohad been ruptured in both groins for twenty years, and hadworn an inefficient truss, which sometimes let the ruptures toslip by it into the scrotum, was seized with vomiting aftereating heartily of pork on the evening of Jan. 1st. For thisa druggist gave him purgatives. As these did not act, andhis disorder increased on the 4th, he was seen bv a medicalman, who, learning he was ruptured, examined his groins,and not finding any swelling there, regarded his symptomsas indicative of an internal obstruction, and prescribed bella-donna and opium. On the following day he first detected aswelling in the right groin, and sent him into the hospital.The swelling was clearly a strangulated bubonocele. The

patient’s cheeks were pale and sunken ; the surface of thebody generally was cold. The pulse was small, weak, andrapid. He vomited frequently, and the matter thrown uphad a faecal appearance and smell. At this stage it wasjudged improper to repeat the taxis, which had already beentried by the former medical man, and herniotomy was donewithout delay. The sac was found to be very thick, andmuch congested. On opening it two ounces of bloodyserum escaped, and the opening being enlarged several coilsof small intestine protruded, the quantity being much greaterthan could have been contained in the inguinal canal. Mostof this intestine had occupied a deeper part of the sac lyingdeeply in the belly between the fascia transversalis and theperitoneum. By drawing this down the neck of the sac,which constituted the constriction, was brought within reachand divided, after which the gut, very congested andthickened, but not gangrenous, was easily replaced in theperitoneal cavity. The wound was washed out with chlorideof zinc solution (forty grains to one ounce of water), and adrainage-tube inserted. A slip of oiled silk, covered by a padof boric lint, secured by a bandage, completed the dressing.He passed a copious loose stool the same evening. Hisrecovery was nninterrupted, and on the 16th of the month,eleven days after the operation, he was able to return home.The anatomical circumstance3 disclosed at the operationleave no doubt that by an improper application of the taxisby the patient himself the upper part of the sac had beendetached from its connexions in the inguinal canal, andthrust up more deeply in the belly, becoming bulged andpunctured, but not torn. The straining attending the con-tinued retching forced it again into the canal, and led to itsdetention here.CASE 5. Large Strangulated Scrotal Rupture; Operation

one hour after the accident; Sac Unopened; Quick Re-covery. (From notes by the dresser, Mr. G. Cree.)-Anenameller, aged forty, whilst at his furnace felt sick, as hethought, from the metallic fumes rising from his work, andbeginning to vomit found his scrotum swell, and he wasseized with severe pain in it and in the belly. When admittedinto the hospital soon afterwards he was found to have anextremely ten!;e scrotal rupture, of the size of a cocoa-nut.He was writhing with pain. His face and hands were cold,and bedewed with sweat. He had, lie sa;d, been rupturedlor several years, and had worn a trus. As the ruptaie was

irreducible by taxis, and its great terseness and the seventyof the symptoms indicated a very tight strangulatior, it wassubjected to operation one hour after the onset of the sym-ptoms. After division of the margin of the external ab.dominal ring, and of some tight fibrous bands external tothe neck of the sac. the contents were reduced withoutopening this latter. The bowels acted the same night. The

wound healed by first intention.

KIDDERMINSTER INFIRMARY.TWO CASES OF STRANGULATED HERNIA.

(Under the care of Mr. J. LIONEL STRETTON, honorarysurgeon.)

CASE 1.—E. G-, aged thirty-three, female, unmarried,has been ruptured for two or three years and worn a truss,but latterly has left it off because it was uncomfortable.While straining at her work, carpet weaving, it came down,and she has not been able to return it. She was first seenon May 31st, the following day. She was lying in bed, herexpression anxious ; her bowels had not been open since the29th. She had vomited several times on the 30th; thevomit was said to be of a yellow colour. There has beenno sickness to-day. On examination there was found asmall nodular swelling just below Poupart’s ligament (rightside) in the region of tne saphenous opening. It is slightlyred, very painful to the touch, resonant on percussion, noimpulse on coughing. A slight attempt at taxis was made,and this failing she was ordered into the infirmary. Onadmission she was placed in a warm bath, and a furtherattempt at taxis made, but without success. After con.sultation she was placed under chloroform; another attemptat taxis was made, and this failing it was decided to operate.A vertical incision was made over the tumour and the saccarefully exposed ; but as no constriction could be felt thesac was opened. The constriction was found at the femoratring, which was very high up. The internal edge wasnicked with a herniotome, and the gut easily returned.There was no omentum in the sac, and the gut was quitehealthy though very tightly constricted. The wound wasclosed with silver sutures, a small piece of drainage-tubeinserted at the lower end, and dressed with carbolic oil lint.To have one grain of opium pill at once, and half a grainevery three hours. Iced-water to sip.June 1st: Has had very little sleep. There has been no

sickness. Slight pain in the region of the wound, but nooozing from the dressings. Tongue moist. Temperature 99.8°;pulse 116. To have one grain of opium every four hours.To have milk.-2nd: Has had a better night and feels morecomfortable; passed flatus several times during the night;tongue moist. Temperature 101’4°; pulse 116. To haveopium every six hours.—4th: Patient doing well; is men-struating ; wound dressed, nearly healed, one stitch re-

moved ; opium stopped. Temperature lOGo; tongue cleaning.To have beef-tea.-5th : Wound dressed again, remainingsutures and drainage-tube removed. Complains of dis-comfort ; the abdomen somewhat distended. To haveenema of milk and assafoetida.-7th : There has been noaction of the bowels, still a good deal of distension. To haveenema of gruel, castor oil, and assafcetida. Wound healedexcept ’aperture of drainage-tube. - 8th : Bowels opentwice in the night; she is much more comfortable; tongueclean. To have fish.—]2th: Patient practically well. Tohave mutton chops.-20th : Truss ordered, but owing to asore just below the left anterior superior spine she wasunable to wear it and had to remain in bed a week or solonger, at the end of which time she was discharged cured.

CASE 2 -J. G-, male, aged seventy, married ;’first seenon July 11th at 8.45 P. M. He was in bed complaining of greatpain and sickness, and said, "I think I am ruptured."Upon inquiry he said that be was mowing with a scythe at1 P M. when he felt something give way, and he was seizedwith great pain in his right groin. He was vomiting con-tinually, the vomited matter was curdy, not faecal ; hisbowels had not been open for three or four days; since theaccident he had wanted to stool but could not. Examinationrevealed a small swelling about the size of a walnut in theright groin, a little internal to the centre; it was so tenderthat no minute examination was made, but he was advisedto go into the infirmary. At 10 P. M. he was seen attheinfir-mary, and after a consultation was placed under chloroform,and an attempt at reduction by taxis was made; this failing, the