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UNIVERSITY COLLEGE HOSPITAL.

CONGENITAL INGUINAL HERNIA, STRANGULATEDOPERATION ; SPEEDY RECOVERY.

(Under the care of Mr. HENRY THOMPSON.)

H. P-, aged twenty, a potboy, was admitted into wardTo. 1, at nine A.M., August 29th, with strangulated hernia.He has been the subject of it, he thinks, about five or six years.It rarely descends; but the reduction has always been attendedwith some difficulty, and always been effected by a surgeon. Atsix o’clock this morning, it came down during a fit of coughing.A surgeon was sent for, who tried the taxis, but without suc-cess. On admission, he was suffering pain and marked tender-ness. The warm bath was tried, and the taxis repeated duringthe morning, but still without success. He had a full dose of

opium. No purgative had been administered. The pain andtenderness increased towards noon, and vomiting set in. At

one o’clock Mr. Thompson saw him, and finding the tumourtense and tender, decided on operating without delay. Tt wasdeemed necessary to open the sac. lhe hernia proved to becongenital. The testicle was found lying at the bottom of thesac, and was freely exposed. A knuckle of intestine was dis-

covered, with much omentum, which appeared to have had aconsiderable share in strangling the bowel. He had a dose of

opium immediately afterwards.Aug. 30th.-He i3 comfortable; little pain, evidently colicky.

Ordered, five minims of Battley’s solution every three hours,and half a pint of strong ale, as he has been accustomed tothree pints daily, and expresses a wish for it.

31st.—The patient is much better; flatus has passed freely.To continue the ale, and to have a chop, as he wishes for it.

Sept. 2nd.-Bowels operated; appetite good. Has continuedfull diet.

12th.—Wound healed; perfectly well.14th.-To have a truss, and be discharged.Mr. Thompson remarked that it was not common to get a

case of hernia in which strong purgatives had not been adminis-tered, often very freely, previous to admission. He believedthe action of these, after the bowel was liberated by operation,had often an extremely prejudicial effect; and he attributedsome share in the excellent result to the fact stated. Ordi-narily, he always orders full doses of opium immediately afterthe operation, partly with a view to check the drastic action,which is otherwise apt to be set up. The early exhibition ofstimulants, in this case, appeared to be beneficial; and the’early supply of nourishment, doubtless, contributed to the

rapidity of the convalescence.

WESTMINSTER HOSPITAL.

STRANGULATED INGUINAL HERNIA, RELIEVED BY OPERA-

TION; VOMITING FOR TEN DAYS; PYÆMIA; DEATH FROMBED-SORES ON THE TWENTY-SIXTH DAY.

(Under the care of Mr. HILLMAN.)THE account which follows is a short abstract of a case of

considerable interest, the notes of which have been placed atour disposal by Mr. W. -N. Pell.

S. H-, aged thirty-one, an omnibns conductor, was ad-mitted on the 22nd of last August. He had been the subjectof left inguinal hernia for nine months, but had never worn atruss. The bowel came down on the 21st, and could not bereturned; it now formed a large scrotal tumour. Other treat-ment proving unavailing, and the symptoms being urgent, Mr.Hillman at once operated, but could not return the protrudedparts without opening the sac. The stricture seated at theneck of the sac was divided, and a large quantity of omentum ’’,and a long loop of small intestine were returned into theabdomen. Uninterrupted vomiting, partly fæcal, continuedtill the tenth day, when it partially subsided, on the first occur-rence of relief to the bowels by several dark evacuations.Diarrhoaa now ensued for three days, and pustules and ulcersin great number and of various sizes appeared over the body,first commencing on both little fingers. These were relievedby evacuation of their contents ; the general health being sup-ported by brandy and other stimulants and the most nourish-ing diet. The patient, however, continued in a very low state,

and bed-sores began to form. These, together with generaldebility, continued to increase, and he sank from exhaustionon the 17th of October, twenty-six days after the operation.No post-mortem examination was permitted.

CLINICAL RECORDS.

BLEEDING FROM THE THROAT: LIGATURE OFTHE CAROTID ARTERY.

WE have lately seen two cases in which the tonsils werelanced for supposed abscess, and the instrument had been ap-plied in such an awkward and unskilful manner as to woundthe carotid artery, giving rise to alarming hæmorrhage in eachinstance. Every student is taught that when about to punc-ture an abscess of the tonsil he must do so in a direction in-wards, so as to avoid injuring this vessel.At midnight on the 24th of October, a man, aged twenty-

four, was admitted into St. Bartholomew’s Hospital, withbleeding from the throat. He had an abscess of one of thetonsils (the left), and suffered great agony. Having obtainedprofessional advice, the abscess was punctured on the 21st bya surgeon, and it bled a little. It continued to bleed in small

quantity up to Sunday, the 23rd; and on the Monday, par-ticularly towards evening, he lost a great deal of blood, alto-gether amounting to nearly a pint. He was seen the next dayafter admission by Mr. Stanley. The bleeding recurred occa-sionally up to the 26th, when Mr. Stanley placed a ligature onthe trunk of the common carotid artery, an inch and a halfbelow its division into two branches. This effectually con-trolled the haemorrhage, of which there has since been no re-turn. When we last saw the patient, he was quiet and calm,and going on well, but pallid from the loss of blood. Thesecond instance is that which now follows. The hæmorrhagewas much more extensive.

SEVERE HAEMORRHAGE FROM THE TONSILARRESTED BY THE SOLUTION OF THE

PERCHLORIDE OF IRON.

THE following case of severe beemorrhage admirably illus.trates the beneficial effect of the perchloride of iron as a styptic.Mr. Henry Thompson was called to see it at the MaryleboneInfirmary, at midnight, on the 22nd of October, and took withhim a bottle of the solution of the perchloride of iron (FrenchCodex), and a glass brush. He found a woman propped up inbed, pale and almost pulseless, with a large vessel of coagu-lated blood at her side, and the bedclothes bespattered in everydirection. She could not speak so as to be understood, andfinding that she was bleeding from one or both tonsils, Mr.Thompson passed his finger into the fauces, and discovered asmall opening, as if from incision previously made, in the frontof the right tonsil; blood was evidently flowing fast from it.Binding a piece of lint round the entire left forefinger, so as toform a mop, pressure was kept upon the wound, until he couldapply the solution, which was done freely two or three times.This at once arrested the bleeding, which recommenced in zuquarter of an hour, and was again stopped by the same plan.There was no return after this, and she is now recoveringrapidly.

In default of the aid thus rendered by the styptic solution,Mr. Thompson had made up his mind to tie the carotid artery;but the efficacy of the treatment was so striking, that the ope-ration was not required.

There can be no doubt, as in the foregoing case of Mr. Stan-ley, that the carotid artery was punctured in the followinginstance, the notes of which were taken by the house-surgeonto the Infirmary :-

Sarah 0-, aged thirty-five, charwoman, married, wasadmitted into the Marylebone Infirmary on Saturday, the 22ndof October, at twelve o’clock, mid-day, with acute tonsillitis.At half-past ten the same night, considerable haemorrhage setin, when she lost altogether about three pints and a half ofblood. The hæmorrhage continued till after twelve o’clock,the blood being continually coughed up in large red clots. Shestates that a surgeon saw her on the previous Thursday, andthat he lanced the throat (she does not know on which side).No pus, but about a pint of blood, was lost. The next day, helanced the other side, when about half a pint (as well as shecould judge) of clear blood came away. From that time shehad no bleeding up to half-past ten o’clock on the next night

(Saturday). No blood was lost after the application of the

510

iron. Has been doing very well ever since. The house-snr-

geon found, by measurement with water, that there were threepints of blood in the vessel, besides the quantity about the bed,making quite the other half pint.

BIRTH OF A CHILD THROUGH A CENTRALRUPTURE IN THE PERINÆUM.

As is well known to every accoucheur, when the perinæumbecomes ruptured during labour, it is generally from be-fore backwards. It sometimes happens, however, that insteadof the laceration occurring in that manner, the perineum isperforated at its centre by the head, and the child is bornthrough this opening without passing by the os externum orvaginal outlet. This is a very rare form of injury, and isnoticed in Dr. Rigby’s "System of Midwifery," p. 113.At the present time there is a young woman in St. George’s

Hospital, who was recently confined of her first child (illegi-timate). She was in labour from two o’clock in the morninguntil five in the afternoon ; the head had well descended, andthe perinæum was carefully supported by a practitionerattending upon her, who observed that there was no dispo-sition for the vaginal outlet to dilate, and permit the head tobe born ; but the perinEeum was enormously distended. Sud-

denly the centre of the perinæum ruptured, and the headforced its way through, followed by the body of the child.Birth, therefore, took place without emergence from the os ex-ternum. She was subsequently admitted into St. George’sHospital, and is now under the care of Mr. Pollock. She wasexamined by Dr. Robert Lee, who observed that he had notseen a similar instance, and that it was one of great rarity.The edges of the rupture were brought together by Mr. Pollock;but the sutures ulcerated through, and now suppuration isgoing on between the lips of the wound. The rectum and anusare intact. The rupture commenced in front of the anus, andextended in two directions-on the right side beyond thevagina in an oblique direction, and on the left to about halfthe distance, leaving a tongue-shaped flap of integument point-ing towards the anus. The parts have, however, considerablycontracted since her labour, although the longest wound is

nearly three inches in length.

THE ADHESION OF THE NERVOUS BULBS INSTUMPS TO THE CICATRIX.

THERE is a popular error prevailing amongst many membersof our profession, to the effect that in the painful stumps ofamputated limbs, the pain depends upon the bulbous enlarge-ment of the ends of the divided nerves. That this is not thecause of the uneasiness, however, anyone may satisfy himselfby dissecting old stumps of individuals who may have died ofother diseases, and who have never complained of any incon-venience during life at the seat of amputation. A dissectionwill show the ends of the nerves to be thickened and dilatedin the form of a bulb, this condition depending upon the de-velopment of areolar or fibro-cellular tissue between the minutenervous llbrillse. It is a natural process, and is no doubt in-tended to subserve some useful purpose in the economy. Whena stump is painful, however, it is mostly so in consequence ofan adhesion between these little oval or rounded tumours andthe cicatrix itself, and thus they become subject to direct pres-sure, which keeps up irritation and pain. A case in point hasjust occurred at St. George’s Hospital, under Mr. Pollock’scare, of a young man who underwent a third amputation inthe left leg on the 6th ultimo. The first took place fourteenmonths ago for injury to the foot, when Syme’s operation wasperformed a,t the ankle-joint, the flap being made from theheel, and all the precautions adopted which he enjoins. The

stump healed readily, but it remained painful, and was uselessfor progression; it was also exceedingly cold. Mr. Pollocktherefore performed a second amputation, a little higher up,and the stump healed as before, but again became painful. Itwas determined again to repeat the amputation higher up, atthe upper third of the leg, and this time to adopt Mr. Teale’splan of making flaps. Mr. Pollock considered this plan emi-nently suited to such a case, as the flap was less likely toengage the nerves, which are cut off at right angles behind.This proceeding was therefore adopted, and everything so farhas gone on well: it remains to be seen whether the stumpwill again, for the fourth time, become painful.On examining the amputated stump, the nervous bulbs were

found adherent to the cicatrix-a condition which was presentin the first stump also.

CHOPART’S AMPUTATION IN CLUB-FOOT.

FEET that are rendered perfectly useless for progression inelderly people from deformity, and which resist all the ordi-nary means of treatment, some surgeons consider it best to re-move. If the contraction rights itself, however, before any-thing is done, and the foot is restored to its natural state, it ismost discouraging when the patient lapses into the originalcondition after walking has been attempted for a short time.Such cases are by no means rare, and when they present them-selves for treatment at the general hospitals, amputation ofsuch useless limbs is the course pursued. It was resorted toon the 25th of October, at Guy’s Hospital, by Mr. Cock. Anelderly female had had her left leg in a state of palsy almostsince a child. This was accompanied by retraction of the tendoAchillis. She had some power over the knee, but none overthe foot; the consequence was that the latter assumed thecharacters of a talipes equinus, and she had walked upon theball of the foot, with the heel raised, for many years. Thebones had become enlarged from several attacks of inflam-mation, and the skin about the toes was in a state of ulceration.With rest and other treatment during some weeks’ stay in thehospital, she has been enabled to leave several times; the lame-ness and inflammation, however, return when she begins towalk. The foot, therefore, in its present condition, Mr.Cock looked upon as utterly useless. With the patient’sconsent, he determined to remove a part of it. After theadministration of chloroform, he divided the tendo Achillis,made a semilunar incision, and then amputated through thetarsus, removing the navicular and cuboid bones, with all theparts in front of them, completing his under flap from the soleof the foot, thus performing Chopart’s operation. Very littleblood was lost, the flaps were brought together by sutures, and

’

gently supported by adhesive plaster.’ We have seen the patient since the operation. The healing

process is going on well, and it is believed she will not only beenabled to walk comfortably, but that she may enjoy a better’ state of general health than heretofore.

COMPOUND FRACTURE AND DISLOCATION OFTHE ASTRACALUS.

A MOST unusual and singular form of injury to the foot is tobe seen at Guy’s Hospital, under Mr. Bryant’s care. It oe-curred in a man fifty years of age, who has the look of a personof sixty. In getting off an omnibus, he fell, and so injured hisfoot that the astragalus was dislocated and forced through theskin forwards and outwards, and hung by a piece of membraneto which it was attached. On examination, this bone was dis-covered to be fractured, in addition to its displacement; itwas therefore removed altogether. Both malleoli were intact.Although the man’s general health was not favourable, he isdoing well. Ice was assiduously applied after the injury, andopium given internally, and now the wound has all but healedby suppuration, and he may have a useful foot.

In such injuries to the foot as the one referred to, it is usualto encounter fracture of the tibia or of one of the malleoli,according to the manner in which the foot has been twisted atthe time of the accident. On the 4th of October, the writerobserved a male patient, aged sixty, in the Westminster Hos-pital, under Mr. Brooke’s care, whose right foot and anklewere greatly swollen, from jumping off a vehicle on to hisheel. He thought he was falling, and leaped to save himself,alighting heavily on the os calcis. The jump was, however,direct, without any twisting, which has prevented any seriouslesion to the bones entering into the formation of the ankle-joint.

HEALTH OF LONDON DURING TIIE WEEK ENDINGSATURDAY, Nov. 12TH. -The deaths registered in London,which were 1182 in the week that ended Nov. 5th, were 1051in the week that ended last Saturdav. The deaths from bron-chitis continue to increase; in the last three weeks they were58, 90, and 102; those from pneumonia had risen to 73 in theprevious week, but they declined to 50 last week. Whooping-cough has also declined to 14. There were 21 deaths from

small-pox. Scarlatina maintains a high mortality, and is nowthe most fatal disease in the zymotic class; 98 deaths are re-ferred to it, and 8 to diphtheria.

Last week, the births of 918 boys and 930 girls, in all 1848children, were registered in London. In the ten correspondingweeks of the years 1849-5S the average number was 1592.