ST. MARY'S HOSPITAL.
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121 This fluid, mixed perhaps with decomposing blood, is looked upon by some as a fertile source of peritonitis, and great care is taken to remove it after the sac is opened in the operation for strangulated hernia. In two cases which oc- curred in St. George’s Hospital two weeks ago these facts were particularly dwelt upon. In one of these, a patient seventy-five years of age, when the sac was opened a net- work of white lymph was seen forming a loose kind of inner sac; and in the other case, in which the taxis had been firmly applied, the sac contained a quantity of bloody fluid. The fluid contents of the sac were carefully removed in both these instances before the hernia was reduced, and the patients are both doing well. The following two cases illustrate the same point-namely, that a formidable source of mischief may exist within the sac itself ; and if this is not opened, and sometimes if it is, fatal consequences may be caused thereby after the stricture is relieved. The first case is very peculiar and interesting from the fact of the mucous surface of the bowel having apparently been de- stroyed by the strangulation of the intestine, and the pas- sage through the intestine having subsequently become almost closed by a process of cicatrisation. Mr. Leigh, sur- gical registrar, has obliged us with the notes. CASE 1.—Margaret S-, aged thirty-five, a cook, was admitted into the Princess ward on the 28th of April, 1868, under the care of Mr. Henry Lee. The history she gave was that for about three years she had noticed a swelling in the left groin; but as it did not increase, and caused her no in- convenience, she thought nothing of it, and wore no truss. The morning before her admission she was seized with pain in the swelling and retching, and at 8 A.M. was first sick. She took aperient medicine, but without effect; and on the morning of the 28th, as the sickness and pain continued, she applied for admission. On admission at 9 A.M., she complained of pain in the lower part of the abdomen and sickness. There was a femoral hernia of the left side, the size of a hen’s egg, tense, tender, and without impulse; pulse 92; tongue coated. She was put to bed, and ice applied to the tumour, but soon after fæcal vomiting ensued. At 1 P.M., as the symptoms of strangulation continued, it was determined to operate, and as the patient was unwilling to take chloroform, the operation was performed without it. Mr. Henry Lee made an incision about two inches long over the tumour, dissected down and opened the sac, being unable to reduce the hernia without so doing. The sac con- tained a small knuckle of intestine, very much congested, and about an ounce of bloody serum, and was adherent to the tissues around. The stricture was situated at the crural ring, and was exceedingly tight. After it was divided, the gut was returned. The wound was closed with silver sutures, and a pad and figure-of-8 bandage applied over it. She was ordered beef-tea and twenty minims of tincture of opium three times a day. April 29th.-Passed a quiet night; pulse 96;. free from pain. May 1st.—The bowels have acted naturally twice during the night; pulse 92. The pad and bandage removed; wound healthy, discharging slightly. Ordered ordinary diet and one pint of porter. The patient subsequently progressed favourably ; the stitches were removed, and the wound granulated. June 2nd.-The wound is now quite healed, and the patient supplied with a truss. The bowels are confined, and never act without medicine. Constipation still continued, so she was ordered some pills of extract of aloes and colocynth from time to time. She also complained of dull aching pain at times, when the bowels were confined, in the lower part of the abdomen, but was up and about with her truss on. July 3rd.-About midday she complained of great pain in lower part of abdomen, became suddenly collapsed, and died at once. At the post-mortem examination the next day, old adhe- sions were found in both pleurae, and the lungs were very oedematous. The left side of the heart was contracted and empty; the right side contained a decolorised clot. The valves and structure of the heart were healthy. The intes- tines were much congested, and at the junction of th.3 jejunum and ileum the gut for about an inch was of a dark slate colour, and was adherent to the iliac fossa. Above this point the gut was dilated, quite full, and its coats thickened; below, it was contracted and empty. At the point of adhesion the coats were much thickened by fibrous deposit, which materially constricted the calibre of the canal, so that water could only flow through it in a very small stream. The mucous surface at this point was firmly contracted by a process of cicatrisation after ulceration. The other abdominal viscera were healthy. CASE 2.-Frederick C-, aged twenty-six, a labourer, was admitted into the Fitzwilliam ward on October 5th, 186S under the care of Mr. Holmes. The history given was that he had been ruptured for about nine years, and had always worn a truss. The hernia used occasionally to come down, but could easily be returned. At 9 A.M. on the morning of his admission, he was at work with a truss on that did not fit him, when the hernia came down, and as he could not get it back, he came to the hospital. He had had pain in the abdomen, but no sickness before admission. On admission, at 10.30 A.m., he complained of great pain across the lower part of the abdomen. He was somewhat cold; pulse 100 ; expression anxious. There was a scrotal hernia of the left side, about the size of an ostrich’s egg, tense, tender, and without impulse on coughing. He was put to bed, and a bladder of ice applied to the tumour; but as the hernia remained in the same state, and fæcal vomit- ing set in, at 1 P.M. chloroform was given, and taxis applied, but without success. Mr. Holmes then made an incision about three inches and a half long, over the external ring, and opened the sac, which contained a large amount of small intestine, somewhat bruised, and considerably con- gested. The stricture was divided, and the intestine with considerable difficulty returned. The sac also contained some clotted blood, which came from a ruptured portion of the mesentery. The wound was closed with silver sutures, and a pad and fagure-of-8 bandage adjusted over it. He was ordered beef-tea, and one grain of powdered opium. immediately. Oct. 6th.-There is a good deal of swelling of the scrotum expression anxious; pulse 116. The recti muscles are very rigid, and he complains of great pain and tenderness over, the lower part of the belly. About midday, the bandage, pad, and sutures were removed, and some sanious fluid es- caped. A small conical pad was placed over the internal ring. Fomentation ordered. 7th.-The abdomen is distended with flatus ; pulse 132, very weak and small. There is repeated hiccough and faecal vomiting. A long tube was passed up the rectum, when some flatus escaped, and later in the evening a rue injec- tion, but without relief. Wound gangrenous. 8th.-Is sinking. Pulse very weak, 112 ; skin clammy. The sickness and hiccough continuous. The rue injection repeated without relief. 9th.-Sank and died at 8 P.M. At the post-mortem examination the next day, at 1.30 P.M., a gangrenous wound was to be seen on the left side of the scrotum; the tissues around were black, and infiltrated with air. In the upper part of the inguinal canal could be felt a swelling which resembled a hernia. The lungs were much congested, cedematous, and emphysematous along their free margin. The left ventricle of the heart was closely contracted; the right was dilated, and contained a decolorised clot. Its structure and valves were natural. The liver and kidneys were congested; the spleen small, shrivelled, and the capsule wrinkled. The intestines were much congested, and covered with varicose vessels. The upper half of the small intestine was distended with air and faeces ; the lower half empty. At the junction of the two portions the gut was reduplicated on itself, and the two serous surfaces, where touching each other, were ad- herent. This knuckle of intestine was lodge in the in- guinal canal, to which it was slightly adherent. Thus an almost complete obstruction was formed. On the mucous membrane at this part was a small ulcer. The mesentery corresponding to the strangulated portion was much bruised and ecchymosed, and there were some small clots of blood in various parts of the abdominal cavity. ST. MARY’S HOSPITAL. PROLAPSUS UTERI OF SEVENTEEN YEARS’ STANDING CURED BY OPERATION. (Under the care of Mr. NORTON.) THE patient, whose case is appended, is at the present time—a, yeax and a half after the operation-a milk-carrier
Transcript of ST. MARY'S HOSPITAL.
121
This fluid, mixed perhaps with decomposing blood, is lookedupon by some as a fertile source of peritonitis, and greatcare is taken to remove it after the sac is opened in theoperation for strangulated hernia. In two cases which oc-curred in St. George’s Hospital two weeks ago these factswere particularly dwelt upon. In one of these, a patientseventy-five years of age, when the sac was opened a net-work of white lymph was seen forming a loose kind of innersac; and in the other case, in which the taxis had been
firmly applied, the sac contained a quantity of bloody fluid.The fluid contents of the sac were carefully removed in boththese instances before the hernia was reduced, and thepatients are both doing well. The following two casesillustrate the same point-namely, that a formidable sourceof mischief may exist within the sac itself ; and if this isnot opened, and sometimes if it is, fatal consequences maybe caused thereby after the stricture is relieved. The firstcase is very peculiar and interesting from the fact of themucous surface of the bowel having apparently been de-stroyed by the strangulation of the intestine, and the pas-sage through the intestine having subsequently becomealmost closed by a process of cicatrisation. Mr. Leigh, sur-gical registrar, has obliged us with the notes.
CASE 1.—Margaret S-, aged thirty-five, a cook, wasadmitted into the Princess ward on the 28th of April, 1868,under the care of Mr. Henry Lee. The history she gave wasthat for about three years she had noticed a swelling in theleft groin; but as it did not increase, and caused her no in-convenience, she thought nothing of it, and wore no truss.The morning before her admission she was seized with painin the swelling and retching, and at 8 A.M. was first sick.She took aperient medicine, but without effect; and on themorning of the 28th, as the sickness and pain continued, sheapplied for admission. -
On admission at 9 A.M., she complained of pain in thelower part of the abdomen and sickness. There was afemoral hernia of the left side, the size of a hen’s egg, tense,tender, and without impulse; pulse 92; tongue coated. Shewas put to bed, and ice applied to the tumour, but soonafter fæcal vomiting ensued.At 1 P.M., as the symptoms of strangulation continued, it
was determined to operate, and as the patient was unwillingto take chloroform, the operation was performed without it.Mr. Henry Lee made an incision about two inches long overthe tumour, dissected down and opened the sac, beingunable to reduce the hernia without so doing. The sac con-tained a small knuckle of intestine, very much congested,and about an ounce of bloody serum, and was adherent tothe tissues around. The stricture was situated at the cruralring, and was exceedingly tight. After it was divided, thegut was returned. The wound was closed with silver sutures,and a pad and figure-of-8 bandage applied over it. She wasordered beef-tea and twenty minims of tincture of opiumthree times a day.
April 29th.-Passed a quiet night; pulse 96;. free from pain.May 1st.—The bowels have acted naturally twice during
the night; pulse 92. The pad and bandage removed; woundhealthy, discharging slightly. Ordered ordinary diet andone pint of porter.The patient subsequently progressed favourably ; the
stitches were removed, and the wound granulated.June 2nd.-The wound is now quite healed, and the patient
supplied with a truss. The bowels are confined, and neveract without medicine. Constipation still continued, so shewas ordered some pills of extract of aloes and colocynthfrom time to time. She also complained of dull aching painat times, when the bowels were confined, in the lower partof the abdomen, but was up and about with her truss on.
July 3rd.-About midday she complained of great pain inlower part of abdomen, became suddenly collapsed, and diedat once.
At the post-mortem examination the next day, old adhe-sions were found in both pleurae, and the lungs were veryoedematous. The left side of the heart was contracted andempty; the right side contained a decolorised clot. Thevalves and structure of the heart were healthy. The intes-tines were much congested, and at the junction of th.3jejunum and ileum the gut for about an inch was of a darkslate colour, and was adherent to the iliac fossa. Abovethis point the gut was dilated, quite full, and its coatsthickened; below, it was contracted and empty. At thepoint of adhesion the coats were much thickened by fibrous
deposit, which materially constricted the calibre of the
canal, so that water could only flow through it in a verysmall stream. The mucous surface at this point was firmlycontracted by a process of cicatrisation after ulceration.The other abdominal viscera were healthy.CASE 2.-Frederick C-, aged twenty-six, a labourer,
was admitted into the Fitzwilliam ward on October 5th,186S under the care of Mr. Holmes. The history givenwas that he had been ruptured for about nine years, andhad always worn a truss. The hernia used occasionally tocome down, but could easily be returned. At 9 A.M. on themorning of his admission, he was at work with a truss onthat did not fit him, when the hernia came down, and as hecould not get it back, he came to the hospital. He hadhad pain in the abdomen, but no sickness before admission.On admission, at 10.30 A.m., he complained of great pain
across the lower part of the abdomen. He was somewhatcold; pulse 100 ; expression anxious. There was a scrotalhernia of the left side, about the size of an ostrich’s egg,tense, tender, and without impulse on coughing. He wasput to bed, and a bladder of ice applied to the tumour; butas the hernia remained in the same state, and fæcal vomit-ing set in, at 1 P.M. chloroform was given, and taxis applied,but without success. Mr. Holmes then made an incisionabout three inches and a half long, over the external ring,and opened the sac, which contained a large amount ofsmall intestine, somewhat bruised, and considerably con-gested. The stricture was divided, and the intestine withconsiderable difficulty returned. The sac also containedsome clotted blood, which came from a ruptured portion ofthe mesentery. The wound was closed with silver sutures,and a pad and fagure-of-8 bandage adjusted over it. Hewas ordered beef-tea, and one grain of powdered opium.immediately.
Oct. 6th.-There is a good deal of swelling of the scrotumexpression anxious; pulse 116. The recti muscles are veryrigid, and he complains of great pain and tenderness over,the lower part of the belly. About midday, the bandage,pad, and sutures were removed, and some sanious fluid es-caped. A small conical pad was placed over the internalring. Fomentation ordered.7th.-The abdomen is distended with flatus ; pulse 132,
very weak and small. There is repeated hiccough and faecalvomiting. A long tube was passed up the rectum, whensome flatus escaped, and later in the evening a rue injec-tion, but without relief. Wound gangrenous.
8th.-Is sinking. Pulse very weak, 112 ; skin clammy.The sickness and hiccough continuous. The rue injectionrepeated without relief.9th.-Sank and died at 8 P.M.At the post-mortem examination the next day, at 1.30 P.M.,
a gangrenous wound was to be seen on the left side of thescrotum; the tissues around were black, and infiltratedwith air. In the upper part of the inguinal canal could befelt a swelling which resembled a hernia. The lungs weremuch congested, cedematous, and emphysematous alongtheir free margin. The left ventricle of the heart was
closely contracted; the right was dilated, and contained adecolorised clot. Its structure and valves were natural.The liver and kidneys were congested; the spleen small,shrivelled, and the capsule wrinkled. The intestines weremuch congested, and covered with varicose vessels. The
upper half of the small intestine was distended with airand faeces ; the lower half empty. At the junction of thetwo portions the gut was reduplicated on itself, and thetwo serous surfaces, where touching each other, were ad-herent. This knuckle of intestine was lodge in the in-guinal canal, to which it was slightly adherent. Thus analmost complete obstruction was formed. On the mucousmembrane at this part was a small ulcer. The mesenterycorresponding to the strangulated portion was muchbruised and ecchymosed, and there were some small clots ofblood in various parts of the abdominal cavity.
ST. MARY’S HOSPITAL.PROLAPSUS UTERI OF SEVENTEEN YEARS’ STANDING
CURED BY OPERATION.
(Under the care of Mr. NORTON.)THE patient, whose case is appended, is at the presenttime—a, yeax and a half after the operation-a milk-carrier
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in London ; and though the weights she bears are excessive,there has been no return of the disease, nor have there beenany bearing-down pains. She continues in perfect health.
Mrs. M- had laboured under the severe effects of anextensive prolapse of the womb since the birth of her lastchild, a period of seventeen years. She stated that shewas unable to walk, or in any way to gain a livelihood, andthat she was only free from pain when lying down.On examination, the uterus was found altogether external
to the vagina. It was much enlarged, thickened, and indu-rated, and around the os, and upon different parts of thevagina, were several small ulcerations. Pessaries of variousforms had been used to support the womb, but withouteffect.
Mr. James Lane saw the patient with Mr. Norton, and itwas determined that the operation which Mr. Lane had per-formed on several occasions should be adopted.On the following Wednesday Mr. Norton removed an el-
liptical piece of the mucous membrane about three inchesand a half in length, by two in breadth, from the vesicalwall of the vagina. The cut margins were then broughttogether by means of ten silver-wire sutures, and the uterusreturned to its normal position. The bowels were confined
by opiates till the sixth day, and then relieved by castor oil.The vagina was syringed daily with warm water, and aftereight days the sutures were removed.
Fourteen days after the first operation, Mr. Norton re-moved by a horse-shoe incision rather more than an inch ofthe mucous membrane of the posterior and lateral walls ofthe vagina, including the cutaneous margins of the four-chette. The denuded surfaces were now approximated asin the operation for ruptured perineum, and were firmlyfixed by means of silver-wire quilled sutures. The pro-jecting lips were more evenly adapted by a second row ofwire sutures somewhat deeply placed. As on the previousoccasion, the bowels were quieted by opiates throughoutthe week. The quilled sutures were removed after forty-eight hours, and the others in seven days. On the removalof the quilled sutures a few drops of pus exuded, and theparts around showed some little redness and induration,but these symptoms were relieved by a bread-and-waterpoultice.Within a fortnight after the second operation the patient
left the hospital entirely cured.
LONDON HOSPITAL.THE USE OF CARBOLIC ACID.
AT this hospital, Mr. Maunder has employed carbolicacid under various circumstances, -in the treatment oflarge chronic abscess, in acute abscess of bone, after theremoval of mammary tumours, in incised operation wounds,(as, for instance, hernia and ligature of the arteries), and asa dressing after amputations, both primary and secondary.The most important and interesting case in which Mr.Maunder used the drug was one of ligature of the left com-mon carotid artery, in a private patient, the subject of threesurgical aneurisms. The ligature having been soaked in astrong solution of acid, was cut short, a weak solution waspoured into the wound, and all the sponges and instrumentsemployed in the operation were dipped in the acid solution.The wound was closed over the ligature, and thick pads oflint saturated with carbolic oil were adapted to the wound,and the outer pad was occasionally moistened with the oil.Six days subsequent to the operation the wound was dressedwith carbolic putty, when neither swelling, nor redness,nor secretion was observed. The wound closed over theligature, and in less than a month the patient went to theseaside. Mr. Maunder is of opinion that carbolic acid tendsto prevent and arrest suppuration, to prevent decompositionin abscess cavities, to prevent local inflammatory action,and general inflammatory or traumatic fever. Thus, hethinks, the healing process is expedited, and the dangersof accident and operation wounds greatly diminished.
WESTMINSTER HOSPITAL.THE USE OF CARBOLIC ACID.
MR. HoLT finds carbolic acid, as applied in accordancewith the directions given by Mr. Lister, a very valuable
remedy. He has tried it in a large number of cases, andalthough it does not always succeed, he believes this is morefrom failing health on the part of the patient than from anydefect in the remedy. In the main, however, it can be reliedupon. Indolent, deep abscesses, sinuses, unhealthy ulcers,and such like, are much benefited by its application, and inrecent operations, if the directions are thoroughly carriedout, it certainly promotes immediate union.
GREAT NORTHERN HOSPITAL.RETENTION OF A FARTHING IN THE FOOD PASSAGE OF
AN INFANT FOR SIX MONTHS.
A CHILD seventeen months old was brought to this hos-pital in June last, having, it was said, managed to swallowa farthing. It did not, however, show signs that any articleso unsuited to digestion had been taken. The house-
surgeon, Mr. P. D. Hopgood, prescribed as much solid foodas possible, and small doses of castor oil, but the farthingwas not forthcoming, and the patient disappeared. A fewdays ago, however, the child was sick after taking an un-usually heavy meal, and in the midst of the vomited mattera green mass was seen, which was the farthing, muchcovered with verdigris. The mother said that the child hadseemed to suffer occasionally from pain, had coughed alittle, and lost flesh. Where was the farthing during thesesix months ?
Provincial Hospital Reports.LIVERPOOL SOUTHERN HOSPITAL.
FRACTURE OF THE SPINE WITH DISPLACEMENT; REDUCTION
BY MEANS OF PULLEYS; RECOVERY.
(Under the care of Dr. WOLLASTON.)J. M a clerk, aged thirty-six, while in a state of in-
toxication, walked over one of the pier-heads, and fell on tothe river bed below, a distance of about forty feet. In thisstate he remained for four hours, until he was roused byfeeling the advancing tide. He was hoisted up by ropes,and brought to the hospital.On admission, Nov. 18th, 1868, he was unable to stand,
and complained of intense pain from the toes of both feetup to the hips, and also of a feeling of stiffness in theback. On examining the back there was considerableecchymosis of the lower portion of the dorsal region, andthe eleventh dorsal vertebra was displaced, and protrudedfully an inch and a half from its normal position. No cre-
pitus could be felt. Hyperæsthesia of the lower extremitiesexisted in a most marked degree, a breath of air, or a touchof a feather, causing the most excruciating agony. Withoutany stimulus paroxysms of pain came on every three or fourminutes, commencing at the base of the toes. There wasneither paraplegia nor priapism.
Treatment.—The patient being placed on a mattress onthe floor, chloroform was administered to its full extent.The shoulders were then securely fixed, and the pulleys ap-plied to both thighs. During extension, the hand, placedover the projecting portion of the spine, felt the displace-ment gradually disappear, but without crepitus or jerk.Hot water bottles were applied to the feet, a dose of tinc-ture of opium given, the catheter passed, and the patientdirected to remain on his back.Nov. 19th.-Has passed a restless night, the attacks of
pain being most intense, and with only short intervals.Although he has been tossing from side to side, no dis-placement has occurred, but a slight ° dip " is felt at theseat of injury. One-third of a grain of morphia was in-jected into the calf of one leg, and the legs elevated on pil-lows ; catheter passed. Towards evening, as no relief wasexperienced, the injection was repeated in the other leg,and with immediate benefit. Temperature: upper ex-
tremity, 97°; lower, 985°. Pulse 98.20th.-Feels better, and has slept for some hours; pain
in feet and legs not so intense, unless touched; abdomentympanitic, and he is unable to pass flatus; little or no
