1
571 from the possible injury to its important contents; I am, there- fore fortunate in having been able to verify my case by induc- tion only, and at the same time to have the prospect of seeing my patient again actively employed in the business of life. Subsequently to the removal of the splint much friction was employed with great attendant benefit, and tonics were neces- sary, owing to a naturally weak constitution. Upper Berkeley-street, May, 1860. A Mirror OF THE PRACTICE OF MEDICINE AND SURGERY IN THE HOSPITALS OF LONDON. Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum et dissectionum historias, tam aliorum proprias, collectas habere et inter se com- parare.—MORGAGNI. De Sed. et Caus. Morb., lib. 14. Proœmium. ST. MARY’S HOSPITAL. STRANGULATED OBLIQUE INGUINAL HERNIA; MORTIFICATION OF THE BOWEL; OPERATION; ARTIFICIAL ANUS; RECOVERY. (Under the care of Mr. COULSON.) THE difficulty of constructing trusses which shall accurately and comfortably retain every variety of rupture is admitted, and this difficulty is oftentimes the fertile source of strangula- tion. It is especially amongst working men that this dangerous result is found: the pain, inconvenience, or costliness of various trusses which they may have employed, and the readiness with which complete or partial reduction of the hernial protrusion is effected at the end of the day, induce them to forego the use of any truss. For many years this reduction is daily effected, until accident brings down a larger portion of bowel than usual ; reduction is then difficult, sometimes impossible, and thus dangerous strangulation occurs. In the subjoined case, the strangulation was so acute as to produce mortification of the bowel and an artificial anus; the patient, however, ultimately recovered. W. C-, aged forty-eight, was admitted into the operation ward of St. Mary’s Hospital, under the care of Mr. Coulson, with strangulated inguinal hernia. The rupture was of eighteen years’ standing. He had worn trusses specially made for him at different times, but they had caused him so much pain and inconvenience that, after various trials, he had entirely aban- doned their use. The swelling had never greatly exceeded the size of a pigeon’s egg, and the major part of it had been easily reducible, a small portion, as the sequel showed, remaining irreducible. The day before admission, he found a good deal of bowel down, and was unable to return it. The taxis, warm bath, and castor oil had been ineffectually employed prior to admission. The hot bath, taxis, and chloroform having failed, Mr. Coulson proceeded to perform herniotomy. The sac was opened; no fluid escaped, and the bowel was seen to be black in colour, but still retaining a glossy surface. Another portion of bowel was found in the sac, not strangulated; it was ad- herent and irreducible. Mr. Coulson liberated the stricture by introducing a blunt-pointed bistoury guarded by the finger, and, dividing directly upwards, returned the strangulated in- testine, leaving in the sac the non-strangulated portion, which was firmly adherent. The incision was closed by suture, and a dose of opium administered to the patient. He slept well during the night, but next morning his pulse was 100; he complained of pain in the groin, flatulence, and thirst; the eyes were sunken, and he sweated profusely. He was well supported. It was necessary to draw off the urine. On the third day, the bowels not having acted, an enema of castor oil was administered, which produced a copious evacua- tion. Pulse 130 ; much flatulence, sweating, troublesome cough, and pain in the groin. One suture removed. Charcoal poultices were now applied to the wound, which discharged freely a fetid matter. He was weak, and complained much of abdo- minal and inguinal pain. The bowels were again opened. Next day the sutures were wholly removed, and cataplasms continued. The wound now discharged fxcal matter. As it gaped more freely, the sac was found to be partially sloughing, and a portion of intestine also. Enemata produced natural motions, but free discharge of fmcal matter existed at the groin. After a time the wound cleaned under the applications which Mr. Coulson directed to be made to it, and began gradually to contract, so that five weeks after the operation the opening had nearly closed, and the motions passed entirely by the rectum. This lasted for some days, when the faeces once more broke through the opening in the groin, and from that time they continued to do so. Tonic and sedative remedies were adopted, and the patient was discharged in a fair state of health. ST. GEORGE’S HOSPITAL. THE ENTIRE GREAT OMENTUM AND PORTION OF LARGE INTESTINE INCARCERATED IN AN INGUINAL HERNIA; RECOVERY AFTER OPERATION. (Under the care of Mr. PRESCOTT HEWETT.) IT is a common circumstance to meet with portions of omen- tum in hernia, and sometimes it alone constitutes the tumour which is strangulated. A case of this kind in an old woman, under Mr. Stanley’s care at St. Bartholomew’s Hospital, is re- corded in a previous "Mirror," (THE LANCET, vol. ii., 1858, p. 575.) In that instance it was found necessary to remove the protruded omentnm, as it was in a gangrenous condition. The following example is one of old-standing hernia, be- coming strangulated, and consisting of the whole of the great omentum, with a knuckle of bowel derived from the transverse colon. The omentum was highly congested ; reduction was accomplished without division of the ring, and a good recovery ensued. Many surgeons of authority recommend that the omen- tiim be not returned into the abdomen if the mass protruded be very large, or if it be hypertrophied or otherwise altered in structure, as well as being congested, from the fear of the supervention of fatal epiploitis. In the present example, how- ever, there were no adhesions, and the protrusion, although very large and much congested, was quite recent. The course pursued, therefore, was preferable to excision of the omentum. The case affords another illustration of the variety and diffe- rences constantly presented in cases of hernia. The notes were furnished us by the surgical registrar of the hospital. T. H. W-, aged forty, was admitted on the 7th of February, in the evening, with a large strangulated hernia. Has been the subject of an inguinal hernia for twenty years, which he has always been able to reduce, and for which he has never worn a truss. Has had delirium tremens three times, and is constantly drunk. At twelve o’clock on the day of ad- mission (previous to which hour he had been drinking very hard), he found the hernia down, and was unable to reduce it. He sent for a surgeon, who used gentle taxis; but finding he could not reduce it, ordered some medicine. At three P.M. vomiting came on, and continued without intermission up to the time of admission. The bowels had acted freely since noon... On admission, at half-past nine P.M.. there was an inguinal hernia on the right side, about the size of an orange, which was not very tense or tender. On examination, it was evident that the tumour was principally omentum; ice was not then applied. He had some tenderness of abdomen, which was soft; the tongue was brown and dry; pulse 50, small and weak. A consultation was btld at a quarter-past ten, and chloroform was given at once, in the hope of reducing the tumour. This was not effected ; therefore herniotomy was performed. On laying open the sac, an immense piece of omentum protruded, which was very much congested; and in pulling this out a small piece of the transverse colon was found. This was reduced without dividing the ring, and the whole of the omentum was returned. The wound was brought together with sutures, and thirty-five minims of tincture of opium were administered. Feb. 8th.-Passed a good night; pulse quiet, 84; tongue clean; no pain in abdomen; slight redness of scrotum, which is a little tender. Ordered, beef-tea, two pints. 9th.-Slept well; no pain; redness less; pulse good; skin moist. 11th.-Sutures removed; wound almost healed by first in- tention ; the ligatures not yet separated. l4th.—A ligature came away; two days after, the second ligature came away; and by the 20th, the wound was per- fectly healed. On t,1-." 24th 1-.o was discharged cured

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571

from the possible injury to its important contents; I am, there-fore fortunate in having been able to verify my case by induc-tion only, and at the same time to have the prospect of seeingmy patient again actively employed in the business of life.Subsequently to the removal of the splint much friction wasemployed with great attendant benefit, and tonics were neces-sary, owing to a naturally weak constitution.Upper Berkeley-street, May, 1860.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

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

ST. MARY’S HOSPITAL.

STRANGULATED OBLIQUE INGUINAL HERNIA;MORTIFICATION OF THE BOWEL; OPERATION; ARTIFICIAL

ANUS; RECOVERY.

(Under the care of Mr. COULSON.)THE difficulty of constructing trusses which shall accurately

and comfortably retain every variety of rupture is admitted,and this difficulty is oftentimes the fertile source of strangula-tion. It is especially amongst working men that this dangerousresult is found: the pain, inconvenience, or costliness of varioustrusses which they may have employed, and the readiness withwhich complete or partial reduction of the hernial protrusion iseffected at the end of the day, induce them to forego the use ofany truss. For many years this reduction is daily effected,until accident brings down a larger portion of bowel than usual ;reduction is then difficult, sometimes impossible, and thusdangerous strangulation occurs. In the subjoined case, thestrangulation was so acute as to produce mortification of thebowel and an artificial anus; the patient, however, ultimatelyrecovered.W. C-, aged forty-eight, was admitted into the operation

ward of St. Mary’s Hospital, under the care of Mr. Coulson,with strangulated inguinal hernia. The rupture was of eighteenyears’ standing. He had worn trusses specially made for himat different times, but they had caused him so much pain andinconvenience that, after various trials, he had entirely aban-doned their use. The swelling had never greatly exceeded thesize of a pigeon’s egg, and the major part of it had been easilyreducible, a small portion, as the sequel showed, remainingirreducible. The day before admission, he found a good dealof bowel down, and was unable to return it. The taxis, warmbath, and castor oil had been ineffectually employed prior toadmission. The hot bath, taxis, and chloroform having failed,Mr. Coulson proceeded to perform herniotomy. The sac was

opened; no fluid escaped, and the bowel was seen to be blackin colour, but still retaining a glossy surface. Another portionof bowel was found in the sac, not strangulated; it was ad-herent and irreducible. Mr. Coulson liberated the stricture byintroducing a blunt-pointed bistoury guarded by the finger,and, dividing directly upwards, returned the strangulated in-testine, leaving in the sac the non-strangulated portion, whichwas firmly adherent. The incision was closed by suture, and adose of opium administered to the patient.He slept well during the night, but next morning his pulse

was 100; he complained of pain in the groin, flatulence, andthirst; the eyes were sunken, and he sweated profusely. Hewas well supported. It was necessary to draw off the urine.On the third day, the bowels not having acted, an enema of

castor oil was administered, which produced a copious evacua-tion. Pulse 130 ; much flatulence, sweating, troublesome cough,and pain in the groin. One suture removed. Charcoal poulticeswere now applied to the wound, which discharged freely afetid matter. He was weak, and complained much of abdo-minal and inguinal pain. The bowels were again opened.

Next day the sutures were wholly removed, and cataplasmscontinued. The wound now discharged fxcal matter. As it

gaped more freely, the sac was found to be partially sloughing,and a portion of intestine also. Enemata produced naturalmotions, but free discharge of fmcal matter existed at the groin.

After a time the wound cleaned under the applications whichMr. Coulson directed to be made to it, and began gradually tocontract, so that five weeks after the operation the opening hadnearly closed, and the motions passed entirely by the rectum.This lasted for some days, when the faeces once more brokethrough the opening in the groin, and from that time theycontinued to do so. Tonic and sedative remedies were adopted,and the patient was discharged in a fair state of health.

ST. GEORGE’S HOSPITAL.

THE ENTIRE GREAT OMENTUM AND PORTION OF LARGE

INTESTINE INCARCERATED IN AN INGUINAL HERNIA;RECOVERY AFTER OPERATION.

(Under the care of Mr. PRESCOTT HEWETT.)IT is a common circumstance to meet with portions of omen-

tum in hernia, and sometimes it alone constitutes the tumourwhich is strangulated. A case of this kind in an old woman,under Mr. Stanley’s care at St. Bartholomew’s Hospital, is re-corded in a previous "Mirror," (THE LANCET, vol. ii., 1858,p. 575.) In that instance it was found necessary to removethe protruded omentnm, as it was in a gangrenous condition.The following example is one of old-standing hernia, be-

coming strangulated, and consisting of the whole of the greatomentum, with a knuckle of bowel derived from the transversecolon. The omentum was highly congested ; reduction wasaccomplished without division of the ring, and a good recoveryensued. Many surgeons of authority recommend that the omen-tiim be not returned into the abdomen if the mass protruded bevery large, or if it be hypertrophied or otherwise altered instructure, as well as being congested, from the fear of thesupervention of fatal epiploitis. In the present example, how-ever, there were no adhesions, and the protrusion, althoughvery large and much congested, was quite recent. The coursepursued, therefore, was preferable to excision of the omentum.The case affords another illustration of the variety and diffe-rences constantly presented in cases of hernia. The noteswere furnished us by the surgical registrar of the hospital.

T. H. W-, aged forty, was admitted on the 7th ofFebruary, in the evening, with a large strangulated hernia.Has been the subject of an inguinal hernia for twenty years,which he has always been able to reduce, and for which he hasnever worn a truss. Has had delirium tremens three times,and is constantly drunk. At twelve o’clock on the day of ad-mission (previous to which hour he had been drinking veryhard), he found the hernia down, and was unable to reduceit. He sent for a surgeon, who used gentle taxis; but findinghe could not reduce it, ordered some medicine. At threeP.M. vomiting came on, and continued without intermissionup to the time of admission. The bowels had acted freelysince noon... On admission, at half-past nine P.M.. there wasan inguinal hernia on the right side, about the size of an orange,which was not very tense or tender. On examination, it wasevident that the tumour was principally omentum; ice was notthen applied. He had some tenderness of abdomen, which wassoft; the tongue was brown and dry; pulse 50, small andweak. A consultation was btld at a quarter-past ten, andchloroform was given at once, in the hope of reducing thetumour. This was not effected ; therefore herniotomy wasperformed. On laying open the sac, an immense piece ofomentum protruded, which was very much congested; and inpulling this out a small piece of the transverse colon wasfound. This was reduced without dividing the ring, and thewhole of the omentum was returned. The wound was broughttogether with sutures, and thirty-five minims of tincture ofopium were administered.

Feb. 8th.-Passed a good night; pulse quiet, 84; tongueclean; no pain in abdomen; slight redness of scrotum, whichis a little tender. Ordered, beef-tea, two pints.

9th.-Slept well; no pain; redness less; pulse good; skinmoist.

11th.-Sutures removed; wound almost healed by first in-tention ; the ligatures not yet separated.

l4th.—A ligature came away; two days after, the secondligature came away; and by the 20th, the wound was per-fectly healed.On t,1-." 24th 1-.o was discharged cured