403HOSPITAL MEDICINE AND SURGERY.HOSPITAL MEDICINE AND SURGERY.

consequently the lungs, though retracted, were not compressedby the air in the pleural cavities, as they would have been ifthe wounds had been such as to favour the entry more thanthe exit of air. Though the wounds were very free, the entryof air into the chest was to a certain amount impeded-atfirst by the child’s clothes and later by the pads which thehouse surgeon applied-so that the inspiratory efforts, whilstfley did draw air into the pleural cavities, still drew sufficientthrough the respiratory passages into the lungs. It is un-

mecessary to refer to the treatment adopted, for it is obviousthat, since there were no adhesions between either lung andthe chest wall, the only chance of survival lay in immediateclosure of the wounds. By the method adopted in doingthis the air left in the pleurae was reduced to a minimum,and that was quickly absorbed. Effusion only occurred on’one side, and that was fortunately absorbed without suppu-ration occurring. Impalement on spikes is aiways a mostserious and generally a fatal accident, and perforation ofboth pleur2e in this way is rarely recovered from. In Holmes’Hystem of Surgery" a case is referred to in which a manrecovered from perforation of both pleuræ caused by the shaftof a chaise, which was forced between the ribs on the left side,through the cavity of the thorax behind the sternum, andmade its exit between the ribs on the right side, withoutinjury to the heart, lungs, or large vessels.

consequently the lungs, though retracted, were not compressedby the air in the pleural cavities, as they would have been ifthe wounds had been such as to favour the entry more thanthe exit of air. Though the wounds were very free, the entryof air into the chest was to a certain amount impeded-atfirst by the child’s clothes and later by the pads which thehouse surgeon applied-so that the inspiratory efforts, whilstfley did draw air into the pleural cavities, still drew sufficientthrough the respiratory passages into the lungs. It is un-

mecessary to refer to the treatment adopted, for it is obviousthat, since there were no adhesions between either lung andthe chest wall, the only chance of survival lay in immediateclosure of the wounds. By the method adopted in doingthis the air left in the pleurae was reduced to a minimum,and that was quickly absorbed. Effusion only occurred on’one side, and that was fortunately absorbed without suppu-ration occurring. Impalement on spikes is aiways a mostserious and generally a fatal accident, and perforation ofboth pleur2e in this way is rarely recovered from. In Holmes’Hystem of Surgery" a case is referred to in which a manrecovered from perforation of both pleuræ caused by the shaftof a chaise, which was forced between the ribs on the left side,through the cavity of the thorax behind the sternum, andmade its exit between the ribs on the right side, withoutinjury to the heart, lungs, or large vessels.

ROYAL SURREY COUNTY HOSPITAL,GUILDFORD.

TWO CASES OF HERNIA OF THE FALLOPIAN TUBE.

(Under the care of Dr. MORTON and Mr. BUTLER.)THE rarity of hernia of the Fallopian tube leads us to

record the following cases of femoral hernia, recently treated.at this hospital, in which the Fallopian tube was included in 1he contents of the hernial sac. Dr. King 1 records an instance of the very rare condition of congenital inguinalhernia of the uterus, left tube, and ovary. A radical operationwas performed, and the patient died from cardiac failure on the fifteenth day. References to the condition are to be met iwith in writings by Lavater, Voigt, Aubry, Fere, and Brunner.2The condition appears to have been first described by Bessier,and has only been met with in femoral and inguinal hernias.There are several cases mentioned in English literature ofinclusion of ovary and even of uterus in hernia, but nonehitherto of inclusion of the extremity of the Fallopian tube.For the notes of these cases we are indebted to Mr. CharlesFrier, house surgeon.CASE 1 (under the care of Dr. Morton). —A woman forty-

six years of age sought advice at the out-patient department,of the Royal Surrey County Hospital on account of a swelling’in the right groin. She had had a swelling there constantlyfor two years, and it had suddenly become larger five daysbefore she attended the hospital. There had been no actionof the bowel for five days. The swelling was tender tothe touch and gave the impression of an inflamed glandsoftening in the centre. A simple enema was adrninis-tered and produced a considerable evacuation. Fourdays later an incision was made over the swelling throughtissues which were of almost cartilaginous density. This

exposed a rounded, grey, translucent mass, which lookedalmost like the colon, but was in reality the thickened sac.On opening the sac a small quantity of coffee coloured fluidescaped. The sac contained some omentum and an irregular,varicose-looking mass, attached to one end of which weresome congested papillary projections. These latter provedto be the Fallopian tube and its fimbriated extremity. Thetube and omentum were returned and the sac was ligaturedand cut away. The wound healed by first intention.CASE 2 (under the care of Mr. Butler).-A woman was

admitted to the Royal Surrey County Hospital suffering froma strangulated right femoral hernia, which bad been downfor five weeks. The symptoms of strangulation were of afortnight’s duration. A simple enema produced a copious.evacuation, and this was followed by a copious naturalevacuation some hours later. Herniotomy was performed,and the sac was found to contain gangrenous omentum andgangrenous ruptured bowel. The peritoneal cavity contained

THE rarity of hernia of the Fallopian tube leads us to record the following cases of femoral hernia, recently treated.at this hospital, in which the Fallopian tube was included in 1he contents of the hernial sac. Dr. King 1 records an instance of the very rare condition of congenital inguinalhernia of the uterus, left tube, and ovary. A radical operationwas performed, and the patient died from cardiac failure on the fifteenth day. References to the condition are to be met iwith in writings by Lavater, Voigt, Aubry, Fere, and Brunner.2The condition appears to have been first described by Bessier,and has only been met with in femoral and inguinal hernias.There are several cases mentioned in English literature ofinclusion of ovary and even of uterus in hernia, but nonehitherto of inclusion of the extremity of the Fallopian tube.For the notes of these cases we are indebted to Mr. CharlesFrier, house surgeon.CASE 1 (under the care of Dr. Morton). —A woman forty-

six years of age sought advice at the out-patient department,of the Royal Surrey County Hospital on account of a swelling’in the right groin. She had had a swelling there constantlyfor two years, and it had suddenly become larger five daysbefore she attended the hospital. There had been no actionof the bowel for five days. The swelling was tender tothe touch and gave the impression of an inflamed glandsoftening in the centre. A simple enema was adrninis-tered and produced a considerable evacuation. Fourdays later an incision was made over the swelling throughtissues which were of almost cartilaginous density. This

exposed a rounded, grey, translucent mass, which lookedalmost like the colon, but was in reality the thickened sac.On opening the sac a small quantity of coffee coloured fluidescaped. The sac contained some omentum and an irregular,varicose-looking mass, attached to one end of which weresome congested papillary projections. These latter provedto be the Fallopian tube and its fimbriated extremity. Thetube and omentum were returned and the sac was ligaturedand cut away. The wound healed by first intention.CASE 2 (under the care of Mr. Butler).-A woman was

admitted to the Royal Surrey County Hospital suffering froma strangulated right femoral hernia, which bad been downfor five weeks. The symptoms of strangulation were of afortnight’s duration. A simple enema produced a copious.evacuation, and this was followed by a copious naturalevacuation some hours later. Herniotomy was performed,and the sac was found to contain gangrenous omentum andgangrenous ruptured bowel. The peritoneal cavity contained

1 Sajous, vol. ii., 1891, F. 58. American Journal of Obstetrics, NewYork.

2 See Macready on Hernia.

a large amount of fæcal matter, apparently mixed with pus.The gangrenous omentum was removed and an artificial anusmade, but the patient died from shock twelve hours later. Atthe post-mortem examination the bowel was found to be rup-tured about eighteen inches above the ileo-cæcal valve. Theomentum, small intestine, and cascum were all much mattedtogether, and glued to the surface of the mass so formedwas the end of the right Fallopian tube, which was gangrenousto the extent of about half an inch, having evidently beencaught in the constricting band. The vermiform appendixwas apparently healthy, although the finding of an orangepip in the peritoneal cavity had given rise to a suspicion thatthe appendix might also be involved.

a large amount of fæcal matter, apparently mixed with pus.The gangrenous omentum was removed and an artificial anusmade, but the patient died from shock twelve hours later. Atthe post-mortem examination the bowel was found to be rup-tured about eighteen inches above the ileo-cæcal valve. Theomentum, small intestine, and cascum were all much mattedtogether, and glued to the surface of the mass so formedwas the end of the right Fallopian tube, which was gangrenousto the extent of about half an inch, having evidently beencaught in the constricting band. The vermiform appendixwas apparently healthy, although the finding of an orangepip in the peritoneal cavity had given rise to a suspicion thatthe appendix might also be involved.

HULL ROYAL INFIRMARY.IMPERFORATE ANUS, WITH RECTO-VAGINAL FISTULA, IN A

PATIENT NINETEEN YEARS OF AGE.

(Under the care of Mr. HENRY THOMPSON.)THE variety of imperforate rectum of which this case is an

example-namely, that in which the bowel communicateswith the vagina by an opening in the posterior wall-is, of all,the most favourable. There is less risk to life and also a

greater chance of effecting ultimate cure. Mr. Cripps givestwelve cases, in eleven of which recovery followed opera-tion. He recommends that where possible operationshould be postponed to allow the parts to thicken. Dr.Karl Abell records a case somewhat imilar to this in theArchives of Gynæcology (New York) the year before last. Itwas that of a young woman twenty years of age, who frombirth had passed her motions through the vagina. Therectum opened into the vagina slightly in front of thefourchette. A serviceable sphincter was present, and thewoman had as good a control over her faeces as if the arrange-ment had been normal. For the notes of this case we areindebted to Mr. Sutcliffe, house surgeon.The patient was sent to the Hull Infirmary by Mr. Calvert

of Beverley on Sept. 25th, 1893. The mother stated that the

girl was a week old before the nurse found out that there wasany malformation. When five or six weeks old Mr. Thompsonof Beverley "tried to make a proper opening," but failed todo so. Wnen fourteen months old she was brought to theHull Infirmary and examined. Nothing was done, but themother was advised to bring her again when fourteen or fifteenyears old. During the whole of her life of nineteen yearsthe girl has never had control over defecatior, but duringchildhood she had relief without the administration ofan aperient, although the mother stated that up to admis-sion to the Hull Infirmary she had never known her topass a "formed" motion. Seven or eight years ago shebegan to suffer from attacks of "sickness and purging."At first these attacks only occurred at intervals of threeor four months, but latterly there had been only, as a

rule, an interval of a month or so. During these attacksshe had stercoraceous vomiting and constant passage offluid motions. The patient had never menstruated, butshe had always been an active, intelligent gir), and she hadattended school regularly in spite of her inconveniences. Onadmission to hospital the patient was an ill-developed girl,looking more like thirteen than nineteen years old. No traceof anus could he seen, but there was the mark of a cicatrixon its proper site ; the hymen was absent and the vagina

, capacious. Just within the vagina and on its posterior sur-face there was a round aperture through which the tip of the

first finger could with difficulty be passed into the rectum.The latter was felt to be loaded with a huge accumula-tion of fseoes, which probably extended through the wholeof the large intestine. The cushion between the finger intro-

3 duced into the rectum and the external skin opposite thei proper site of the anus was about an inch in thickness.1 Ether was administered, and the house surgeon, aftertwo hours’ hard work, by means of injections, &c , appa-s rently to a great extent cleared the rectum and lower,1 bowels through the vaginal fistula. Nothing further was

done at that time on account of the bruising, stretching, &c.,cl that had occurred. In spite of constant doses of sulphate ofd magnesia the intestines again became loaded in the course of-

a few days, although the consistence was much less firm.w

On Oct 7ch the girl was anaesthetised, and after another

THE variety of imperforate rectum of which this case is anexample-namely, that in which the bowel communicateswith the vagina by an opening in the posterior wall-is, of all,the most favourable. There is less risk to life and also a

greater chance of effecting ultimate cure. Mr. Cripps givestwelve cases, in eleven of which recovery followed opera-tion. He recommends that where possible operationshould be postponed to allow the parts to thicken. Dr.Karl Abell records a case somewhat imilar to this in theArchives of Gynæcology (New York) the year before last. Itwas that of a young woman twenty years of age, who frombirth had passed her motions through the vagina. Therectum opened into the vagina slightly in front of thefourchette. A serviceable sphincter was present, and thewoman had as good a control over her faeces as if the arrange-ment had been normal. For the notes of this case we areindebted to Mr. Sutcliffe, house surgeon.The patient was sent to the Hull Infirmary by Mr. Calvert

of Beverley on Sept. 25th, 1893. The mother stated that the

girl was a week old before the nurse found out that there wasany malformation. When five or six weeks old Mr. Thompsonof Beverley "tried to make a proper opening," but failed todo so. Wnen fourteen months old she was brought to theHull Infirmary and examined. Nothing was done, but themother was advised to bring her again when fourteen or fifteenyears old. During the whole of her life of nineteen yearsthe girl has never had control over defecatior, but duringchildhood she had relief without the administration ofan aperient, although the mother stated that up to admis-sion to the Hull Infirmary she had never known her topass a "formed" motion. Seven or eight years ago shebegan to suffer from attacks of "sickness and purging."At first these attacks only occurred at intervals of threeor four months, but latterly there had been only, as a

rule, an interval of a month or so. During these attacksshe had stercoraceous vomiting and constant passage offluid motions. The patient had never menstruated, butshe had always been an active, intelligent gir), and she hadattended school regularly in spite of her inconveniences. Onadmission to hospital the patient was an ill-developed girl,looking more like thirteen than nineteen years old. No traceof anus could he seen, but there was the mark of a cicatrixon its proper site ; the hymen was absent and the vagina

, capacious. Just within the vagina and on its posterior sur-face there was a round aperture through which the tip of the

first finger could with difficulty be passed into the rectum.The latter was felt to be loaded with a huge accumula-tion of fseoes, which probably extended through the wholeof the large intestine. The cushion between the finger intro-

3 duced into the rectum and the external skin opposite thei proper site of the anus was about an inch in thickness.1 Ether was administered, and the house surgeon, aftertwo hours’ hard work, by means of injections, &c , appa-s rently to a great extent cleared the rectum and lower,1 bowels through the vaginal fistula. Nothing further was

done at that time on account of the bruising, stretching, &c.,cl that had occurred. In spite of constant doses of sulphate ofd magnesia the intestines again became loaded in the course of-

a few days, although the consistence was much less firm.w

On Oct 7ch the girl was anaesthetised, and after another

1 See also Sajous, vol. v., 1892, F. 8.