No. 1442.

APRIL 19, 1851.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. THOMAS’S HOSPITAL.Two Cases of Strangulated Femoral Hernia in Male Subjects;

operations according to different methods; one death; one re-covery.

(Under the care of Mr. LE GROS CLARK.)

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum, etdissectionum historias, tum aliorum proprias, collectas habere et inter secomparare.-MoRGAGNl. De Sed. et Caus. Morb., lib. 14. proaemium.

Is the sac, in operations for strangulated hernia, invariably tobe opened, or to be respected by the knife ? 1 We doubtwhether it would be safe to answer this question absolutely;much must depend on the peculiar circumstances and symp-toms of a given case, and there may be some danger in adher-ing too firmly and too exclusively to any one method. This

position has been lately very instructively illustrated, by twocases operated upon by Mr. Le Gros Clark, in the first ofwhich he followed the plan advocated by Dupuytren, Sir A.Cooper, and others; and in the second, the rules laid down byPetit, Luke, &c. Our readers will recollect that we broughtbefore them, a short time ago, (THE LANCET, March 8, 1851, p.266,) a case under the care of Mr. Hancock, who is a warmadvocate of Dupuytren’s method, where the sac was openedwith good results; we have now much pleasure in recordingMr. Clark’s cases, and shall in future do our best in givingpublicity to facts bearing upon the above-mentioned highlypractical question.

CASE 1.-Operation by Opening the Sac.-James M-sixty-five years of age, a gentleman’s servant, of spare makeand temperate habits, was admitted into William ward, onFeb. 3, 1851. He stated that he had been the subject of asmall rupture (crural) for forty years. It varied but little insize, and was never quite reducible. As it gave him notrouble, he never wore a truss. Three days before his admis-sion, he was seized, without assignable cause, with pain in theabdomen; the hernial swelling increased in size, and vomitingand hiccough followed. Aperients were given, but rejected,the bowels remaining obstinately constipated. When therupture was discovered, taxis had been employed in vain; andwhen the patient was admitted, symptoms of strangulated in-testine had existed for nearly three entire days.

’ The femoral tumour (which extended over Poupart’s liga-ment) was tense, acutely painful, and about the size of agoose’s egg. There was some fulness of the belly, and uneasi-ness, rather than tenderness under pressure. The urgency ofthe symptoms, and the length of time they had persisted, in-dicated the necessity of affording prompt relief with the knife:therefore, after the taxis had been gently repeated for a fewminutes in the warm bath, the operation was performed byMr. Le Gros Clark, the sac being opened, and a very tightand sharp stricture divided in the usual way. The sac wasmuch thickened; it contained a small quantity of limpidserum, and a considerable portion of omentum, spread out infront of, and completely hiding, a knuckle of intestine of adeep purple hue. The bowel was returned; but the omentum,being to some extent adherent to the anterior part of the sac,was left. The patient was ordered to be kept perfectly quiet,and no medicine was given.

In the evening he was restless, low, and sick. A littlebrandy and soda-water was ordered by the house-surgeon; thebelly was fomented, and an enema administered, which wasreturned without fseculent matter.On the following morning, (Feb. 4,) after an indifferent

night, the patient’s pulse rose to 112; face flushed; belly tym-panitic, but almost free from tenderness; tongue moist; vomit-ing frequent. A second enema had brought away some f2ecalmatter in solution; an effervescing mixture was ordered, andlight farinaceous food, as it could be taken. ’,

In the evening of the same day profuse purging supervened; Iafter which the patient expressed himself as feeling greatlyrelieved, and the abdomen became softer and less tumid,though the vomiting continued. The wound was examined

and found, on removal of the compress, in a healthy con-cli-tion.On the second day after the operation, the symptoms of

constitutional disturbance and sickness continuing unabated,brandy was given in small quantities, with soda-water, andwith arrow-root. This afforded relief, and some hours’ inter-mission of the distressing vomiting. The lull was, however,delusive, for the sickness returned with increased violence,the matter rejected being dark in colour, profuse in quantity,and latterly very offensive. He died, much convulsed, on themorning of the third day, having survived the operation aboutsixty hours.

Post-mortem :Examination.-I3ut little fluid, and no lymph inthe abdomen; a few specks of ecchymosis here and there onthe intestines, but no signs of active inflammation. Thestrangulated bowel (a portion of ileum, including the wholecalibre, and about two inches in length) was found occupyingthe position to which it had been returned at the operation,and was curved upon itself; some slight recent adhesionsglued it to the neighbouring peritonaeum. There was a con-siderable quantity of air in the intestine above this point,though the bowel below it was comparatively empty. The

seat of strangulation was distinctly defined, and the appear-ance of the intervening intestine presented very nearly thesame character as at the operation; it had not given way atany point.Mr. Le Gros Clark remarked on this case, that it belongedto a class, unfortunately of too frequent occurrence in hospitalpractice, when the patient, either from negligence, obstinacy,or ignorance, suffers a disease of a fatal tendency to exist toolong for operative interference to hold out much hope ofsaving life. The same cause operates indeed prejudicially inprivate practice, though to a less extent, the motive for con-cealment (principally among females) having a differentorigin. Such being the fact, the difficulty of arriving at sta-tistical conclusions by which justice can be done to the opera-tion for an irreducibly strangulated hernia, is very great.Few surgeons would, however, deny the assertion, that if hadrecourse to at an earlier period, operations would present afarless extensive catalogue of fatal issues.

There was very little difficulty in referring the present to alarge category of cases-viz., those in which a second hernialprotrusion is suddenly superadded to one (generally omentum)of long standing, and frequently neglected or scarcely noticed.This condition had been predicted from the history of thecase. Mr. Clark observed, further, that he did not attach thesame importance that many did to the exposure of the peri-tonseum and contents of a strangulated hernial sac, as hebelieved the serous membrane, already the seat of a morbidaction, was far less susceptible of such influence as the pre-sence of air than it is when performing its functions healthily.He (Mr. Clark) considered the noxious consequences ascribedto this cause as due to other and not less palpable causes,whilst he deprecated any but the gentlest handling of the ex-posed parts. Peritonitis is not so commonly connected withthe fatal termination of this class of operations as has beenaffirmed by many. Active inflammation, as in the presentinstance, is often found altogether absent, or its amount andproducts are by no means sufficient, alone, to account for death.The active purging in the above case was probably, in great

measure, due to purgatives taken before the patient’s admis-sion ; in part, perhaps, to the saline mixture prescribed toallay the sickness. Be that as it may, the temporary reliefexperienced was considerable, though probably it may haveoperated, from its severity, prejudicially on the patient.Altogether, the case was a perplexing one as regards treat-ment, and its prognosis from an early period unfavour-able. Mr. Clark thought that in this as in similar cases themischief done to the intestine may be classed, in its generaleffect, with violence and lesion sustained by the spinal cord.The restorative powers of nature are unequal to the taskwhich is set them; the relief of the strangulation is sufficient,at such a crisis, to arrest the actual death of the part; but noattempt at restoration of healthy function is made. Thewave of peristaltic movement flows rhythmically onward tillit reaches the affected part, and then is reflected on itselftill it returns to the stomach, whence the contents of thebowels are forcibly ejected.Whether in the present case this torpid condition of the

affected intestine were passively overcome during the purging,Mr. Clark did not pretend to say: probably so. The foldingof the intestine, as it lay within the abdomen, was certainlyinsufficient to have interfered with the active propulsion ofthe contents of the bowel in either direction.

430

The matter vomited was of that common character desig-nated as " coffee-grounds" in appearance. It did not appearto partake of a fsecal character at any time, though offensiveat the last. It was probably in great measure poured outfrom the surface of the mucous membrane.

CASE 2.—Op6M)M without opening the sac.-Thomas G.,fifty-nine years of age, a sawyer, healthy and temperate,was admitted into William ward, on Sunday, March 16, 1851.He stated that he had been the subject of rupture for twentyyears, that he had worn a truss habitually for a long period,but had thrown it aside during the last three months. Thehernia came down during the day, but was always readilyreducible. On awaking at six A.M., on the morning of hisadmission, he became conscious of unusual uneasiness aboutthe rupture, which, on feeling, he found larger than usual,tender, and irreducible. Through the day, the tenderness ofthe tumour and abdominal uneasiness (especially referred tothe lower part) became more distressing; but there wasneither sickness nor hiccup. The bowels had acted aboutseven A.M.

The warm bath, with taxis, were tried on his arrival at thehospital in the middle of the day, and an injection, which wasadministered by Mr. Le Gros Clark’s direction, was returnedwithout any solid fseculent matter. When Mr. Clark saw thepatient at nine P. M., the tumour, which was about the size ofan orange, was full, but soft; it was a femoral rupture, and layabove Poupart’s ligament: very tender when handled, and noimpression could be made by the taxis, in varied positions ofthe body, pulse quiet. Mr. Clark determined at once tooperate, and considering the present a favourable case fordividing the stricture without opening the sac, and as offeringmany features of marked contrast to the one just reported,though the same form of hernia, he proceeded as follows:-Aperpendicular incision was made by piercing the skin, thecentre of the cut corresponding to the upper border of thetumour, and rather to its inner side. Mr. Clark readilyreached the crural ring, and had but little difficulty (without.seeing the sac) in dividing the anterior margin of Poupart’s,ligament, passing the hernia knife along the forefinger. Itwas expected that the taxis would be immediately effectual,but it was otherwise; no impression could be made on the itumour.On searching carefully, Mr. Clark felt, about half an inch

from the crural ring, two or three delicate tendinous bands,stretched, like horsehairs, across the neck of the sac, and hefound it necessary to expose the sac in part, in order safely topass a director beneath these bands. It was not until thelast was divided that the contents of the sac yielded, andthen they passed up readily. There was some difficulty inretaining the protruded bowel after reduction, for the sac waslarge,and the size of the crural ring (even before extension withthe knife) much greater than usual. The sac was not opened.The wound was closed with a suture; and a compress, con-

fined by a bandage round the thigh and pelvis, was appliedfirmly over the crural ring. Farinaceous diet. No medicine.On the following day the patient was quite comfortable,

though there was some little reaction, as evidenced by aflushed face and quickened pulse. Some uneasiness, but notenderness, was felt over the lower part of the abdomen;owing to a troublesome cough, it was difficult to keep thehernia up when readjusting the bandage; otherwise the patientwent on favourably.On the third day there was a blush of inflammation ex-

tending from the wound over the crest of the ilium, for whicha light bread-poultice was applied; and as the bowels had notbeen relieved, a dose of castor-oil and some compound squillpill, to relieve the cough, were ordered. On the fourteenth dayfrom the operation the patient was convalescent, and thewound nearly healed.Mr. Clark remarked on this second case, that it offered

some interesting points of contrast with the preceding; he re-garded the two cases as constituting each a type of that classwhich should be subjected to the different forms of operationadopted. In the second, there could be no reasonable groundfor apprehending other than a favourable result of the opera-tion which was adopted, inasmuch as the symptoms were notof that urgent character, nor had the strangulation of thebowel existed sufficiently long to countenance the opinionthat any serious change had taken place in the contents ofthe sac. It might be urged, Mr. Clark remarked, that per-haps the operation was unnecessary; but such opinion couldnot be entertained by any one who had witnessed the unsuc-cessful efforts at reduction by the taxis, or had felt the tight,contracted character of the stricture.He (Mr. Clark) observed further, that the operation offered

an interesting illustration of the practical value of Mr. Luke’sremarks on the subject of Petit’s operation, in a paper readby him before the Medico-Chirurgical Society, and publishedin their Transactions: The present case was an exact illus.tration of a class referred to by Mr. Luke, in which the seatof stricture is clearly independent of the crural ring itself.Mr. Clark expressed his opinion that no good was effected bythe division of Poupart’s ligament in this instance, and that adivision of the strangulating bands described would haveeffected all that was required.

GUY’S HOSPITAL.Cases of Typhus and Ague treated by Dr. Warburg’s

Fever Drops.(Under the care of Dr. BABINGTON.)

WE noticed, during the last few weeks, that several physi-cians of metropolitan hospitals were putting to the test atincture of Dr. Warburg, which is held to possess an almostunfailing efficacy in various kinds of fever, and especially in-termittents. We were naturally led to inquire into the his-tory of this remedy, as its virtues were much extolled, andbecause the trials were conducted by some of our most respectedphysicians. We had first to surmount the instinctive distrustwhich all regular practitioners feel for secret remedies: hereinwe were greatly assisted by the fact that the tincture is beingintroduced to the notice of the public under the auspices ofthe profession; that Dr. Warburg is furnishing large quanti-ties of it gratuitously, for the purpose of getting it fairlytested; and that James’s powder and Battley’s sedative solutionare not the less efficacious for their composition being un-known.The tincture has been for several years before the medical

profession in various parts of the globe; and it would appearthat it has maintained its ground in a very satisfactory manner,particularly for the rapid cure of intermittents, wherein it isstated to be superior to quinine. It is said to have likewisegreat control over typhoid fever, icterus, &c.; but its powersare most conspicuous in ague. In referring to a pamphlet bySir Andrew Halliday, " On the Sickness and Mortality in theWest Indies," published in 1839, we find passages bearingupon the fever drops, which will throw some light on the sub-jcct. Sir Andrew, after stating that the quinine had failed inDemerara, says, (p. 21:) "I was induced to have recourse toa remedy which had already become known in the colony, andwas much talked of as Dr. Warburg’s fever drops.... These,the doctor assured me, were prepared from plants, the virtuesof which he had ascertained during his sojournings with thenative tribes.... It was administered in about fifty of ourworst cases, and under my own eye, with the most perfectsuccess."The medicine has since that time travelled far and wide; it

was found very useful in our eastern possessions, and has beensince introduced into the Austrian Pharmacopoeia. We beg topresent the following cases to our readers, in order that theymay become acquainted with the usual effects of the remedy,and to facilitate any further inquiries they may wish tomake. The value of the medicine must, however, be deter-mined by a more extended series of facts than our limits willallow us to enter upon. We leave this task to the discovererhimself, and subjoin some cases from Guy’s and St. Bartholo-mew’s Hospitals. -

CASE 1. Typhus. (Notes by Mr. Eldrid.)-John E-, agedsixteen; ill seven days; was admitted into Job ward, Jan. 22,1851, under the care of Dr. Babington. He had all the symp-toms of typhus, with profuse diarrhoea, and subsequently largeevacuation of blood.He was treated by astringents, wine, &c., for about a fort-

night, the symptoms being a little improved by the treat-ment. Muttering was still going on, though the diarrhcea andevacuation of blood had ceased, when he was given Warburg’stincture-thirty minims every fourth hour.Two days afterwards there was an evident change for the

better-the tongue became more cleanandmoist, consciousnessincreased, and the bowels were opened but once a day; thepatient passed good nights; the skin was moist; and therewas decidedly less pain over the abdomen on deep pressure.On the ninth day after the use of the tincture had been begunhe was fast convalescing, and was discharged a few days after-wards, having taken some carbonate of ammonia for a shorttime.The tincture was tried in an inveterate case of chorea: it

seemed to act beneficially for some days, but the improvement* Volume tbirty-first.