No. 1895.

DECEMBER 24, 1859.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

KING’S COLLEGE HOSPITAL.THE RADICAL CURE OF HERNIA BY WOOD’S OPERATION;

SUCCESSFUL IN FOURTEEN CASES.

(Under the care of Mr. WOOD. )

hiulla est alia pro certo nosccndi via, nisi quam plurimas et morborum etdissectionum historias, tam aliortim proprias, collectas habere et inter se com-parare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium.

ON Saturday, November 19th, Mr. Wood brought before thepupils a young man, aged seventeen, on whom he had per-formed four months ago his operation for the radical cure ofhernia. The case was a scrotal hernia of sixteen months’

standing. The patient had never worn a truss. The internal

opening was the largest he had ever dealt with, admitting withease the tips of four fingers, with thin and lax abdominalmuscles. With a view of fairly testing the efficacy of the cure,the case had been left subsequently to the operation, altogetherwithout truss. Its present condition fully justified the expec-tations of the operator. The inguinal canal was entirely closed,the descent of the gut being evidently arrested at the upperpart of the canal, notwithstanding that during the four monthsconsiderable muscular exertion had been used by the patient.When admitted into the hospital, the boy was in a low state

of health, and either on that account or from the great strainupon the ligatures, resulting from the size of the internal open-ing, there was considerable burrowing of matter a week afterthe operation between the abdominal muscles along Poupart’sligament. This was attended with much swelling of the abdo-men, but not so much general tenderness on pressure as tojustify entirely the suspicion of peritouitis. There was no sick-ness nor vomiting whatever, and no obstruction of the bowels ;on the contrary, diarrhoea was present for some days, attendedwith the discharge of much flatus. The distension was re-moved by the administration of an enema of as,5afa-tida throughthe long rectum tube. The pus afterwards escaped freelythrough the upper and lower openings by pressure and the useof drainage tubes, and gradually the discharge lessened andceased altogether, and the openings closed up, leaving greathardness and consolidation in the inguinal region. The boywas afterwards sent to Margate for the benefit of sea air, andhad now completely recovered his health and strength. Thecure was in all respects most satisfactory.Mr. Wood stated that he had himself operated in this method

upon fourteen cases, which had been quite indiscriminatelytaken as they applied to him. In one instance only was the cureat present doubtful. This was the case in which varicocelehad appeared on the third day, necessitating the removal ofthe pad and ligatures. The patient was exhibited in thetheatre some time ago. when the varicocele was still persistent,and some effusion into what was apparently the lower part ofthe original sac cut off from the peritoneum, but no hernialimpulse whatever was observed. All the rest of the cases hadremained perfectly satisfactory cures up to the present time,although in the last four or live cases no truss whatever hadbeen worn after the operation. In one instance, a varicocele wascoexistent with a very long scrotal hernia. Both the herniaand the varicocele were cured by the operation. In the firstcase operated upon, twenty months had elapsed since the ope-ration. The patient remains entirely free from hernial protru-sion. No truss has been worn fur some time, the patienthaving lifted as much as a hundredweight without it. The ’,side operated on seems now quite as strong as the other, theinguinal canal being evidently obliterated. This case was re-ported in our "Mirror" of the 29th of M:ty, 1853. In most ofthe cases, the duration of the treatment was from a fortnightto three weeks. In one or two, the wounds were nearly closed on the tenth day. In none, except the case above alluded to, had there been anv bad symptoms. Mr. Wood now believes

that the constant pressure of a truss after operation not onlymasks the failure of the operation, but promotes the absorptionof the newly-formed tissues, which are depended upon, in mostmethods of cure, for preventing the re-descent of the bowel. Inhis method, the absolute closure of the canal by adhesion ofthe posterior to the anterior wall, so as to obtain a valve-likeaction, preventing a protrusion into the canal, was the effectchiefly relied upon to obviate the reproduction of the hernia.He now recommends only the occasional wearing of a lighttruss during exercise, for a short period, after the cure has beensufficiently tested. The operation had been termed a severeone. This could hardly he said of cases which were, as a rule,well and out of bed in a fortnight or three weeks, and of whichonly one out of fourteen had been kept longer than a month inbed. Nor can it be said to be dangerous in experienced handswhen the symptoms in thirteen were so slight. We may addhere, that Mr. Wood’s operation has been performed in twocases in the Dreaditougltt Hospital with complete success. Itis certainly more scientific and effective than Wutzer’s.

CHARING-CROSS HOSPITAL.

SPONTANEOUS RUPTURE OF A VARICOSE VEIN OF THE LEG

EXTERNALLY, PRODUCING FATAL HÆMORRHAGE.

(Under the care of Mr. CANTON.)A FATAL result from the rupture of a varicose vein is so very

unusual, that many writers actually doubt its occurrence. Onthis point Mr. Howship (" Discrimination and Appearance ofSurgical Disease," p. 145, Lond.) states that a varicose veinbursting externally ought never to destroy life by hæmorrhage ;and it has been said by a distinguished writer (Delpech,"Precis Elementaire") that it never does. The former author

gives the following case :-A. B-, aged nineteen, a butcher’sservant at Walworth, long annoyed by varicose veins, whilekilling a pig was told that his own leg was bleeding. His

companions anxiously but ignorantly tying a handkerchiefabove the knee, increased the haemorrhage, and before a sur-geon could be found, he, in half an hour, fainted and died.Velpeau and Carswell relate instances in which the bleeding

from a varix of the leg proved fatal; and a patient of thelatter expired in the space of little more than ten minutesMany other writers might be referred to who have reportedthese rare and dangerous cases, and we have the opportunityof now placing on record another of considerable interest. Thedetails most accurately describe how the haemorrhage went onquite unsuspected by the patient, and so much blood was lostthat she expired on reaching the hospital. The enlargementwas confined chiefly to the smaller veins, and this is to someextent a rule in women. In his work on the " Diseases of theOrgans of Circulation and Respiration," translated by theSydenham Society, Hasse observes that "It is remarkable thatin men the dilatation usually arises from the trunk or the prin-cipal branches of the saphena; in women, from the minutesttwigs of the cutaneous veins." Possibly the pressure of thegi avid uterus may have a great deal to do with this, and mayexplain the frequency of its occurrence in women who haveborne children, and who generally date their varices from oneof their pregnancies.

E. S-, aged forty, a married woman, was brought to thishospital dead, in the evening, having expired from hxmorrhaoeconsequent on the sudden spontaneous rupture of a varicosevein of the leg. Venous blood was found to be still flowingfrom an aperture not larger than the head of a small pin, andsituated an inch and a quarter above the internal malleolus,close to the inner edge of the tibia. The garters worn werevery tightly bound above the knees, which seemed to be some-what swollen. The veins of both legs were varicose, but thedilatation and tortuosity implicated the smaller more than thelarger vessels. No ulcers were present, nor were any cicatricesto be seen on the legs. There was absence of pregnancy. The

body appeared exsanguined, and was that of a well-formed butdelicately-made woman.The following particulars have been obligingly made out by

Mr. Short, dispenser to the hospital : - The deceased, whileengaged in domestic work at home, felt faint, and sought apublic-house close by for a glass of ale. After standing at thebar for a few minutes, a child close by remarked to her thatthere was a pool of blood round her feet, and at this momentthe poor woman complained of faintness, and instantly fellback into the arms of a person near her. She was immediately