71

was found in the sac. The old adherent fatty omentum wasremoved. The recently protruded omentum was ligaturedwith catgut, and the stump passed into the abdomen. Thesac was dissected out, the neck was ligatured, and the excessremoved. The pillars of the ring were brought together bythree catgut sutures. The excess of skin was removed, andthe margins of the skin wound, after the insertion of adrainage-tube, were brought together by silk and catgutsutures. lodoform and salicylic wool were used as dress-ings. Her pain ceased directly after the operation. She hadsome sickness and restlessness, which were remedied bysubcutaneous injections of morphia.

Dec. 7th.-Fairly well since the operation. No tender-ness. Temperature 101° to 10°; wound disposed to

suppurate.llth. -The wound was dressed last night; much

discharge; suppuration around the sutures; these wereremoved and strapping applied. Boracic dressings wereused. The suppuration gradually diminished, and she leftthe hospital well, with an abdominal bandage, beforeChristmas.

.XeMoa’.—The two above-described cases of umbilicalhernia indicate pretty well the plan of treatment whichshould be adopted in cases where umbilical hernia calls foroperative treatment. In these cases in former times opera-tion had a serious result, and on this account surgeons under-took such operations with fear and trembling. :B0 doubt theproper plan to pursue, when operation is called for, is to cutat once, under antiseptic precautions, into the sac ; to dividethe constricting neck of the sac and return any strangulatedintestine; to remove the omentum, ligaturing it at its neck,and return the stump into the abdomen; then to dissectaway the sac, ligaturing this at its neck. In this way anyblood or inflammatory products are prevented getting intothe peritoneal cavity. To complete the operation the mar-gins of the umbilical aperture are brought together by catgutsutures; the redundant skin is removed, and the edges of theskin wound are brought together by alternate silk and catgutsutures, drainage under the skin wound being used, and anti-septic dressings afterwards applied. In the above two cases,afterreturning the hernial contents a ligature of the neck ofthe sac was first employed, next sutures connecting togetherthe margins of the umbilical aperture, and lastly suturesconnecting the skin wound after the excess of skinhad been removed. Both cases did well, although theywere, as is usually the case, bad subjects for operation.In the first case, after operation there was more or less sick-ness ; but she was pregnant, and it was her usual conditionin previous pregnancies to suffer from sickness and diarrhceafrom the beginning to the end of such period. This casehealed by first intention, as is usual in cases after ovariotomy.In the second case there was some suppuration during thehealing of the wound. In this latter case there was nostrangulated intestine in the sac, but there had been a largeaddition of omentum in its interior. This omentum showedsigns of intense congestion, and might have exerted pres-sure in some way upon intestine. The patient’s pain wasexcessive, as was her vomiting, so as to call for operativeinterference; and this interference has resulted in her havinggot rid of her hernia.

SWANSEA HOSPITAL.HIGH ANEURYSM OF FEMORAL ARTERY ; LIGATURE OF

EXTERNAL ILIAC ARTERY; CURE.

(Under the care of Mr. H. A. LATIMER.)E. A. H---, aged thirty-four, a fitter by occupation, was

admitted on Sept. 7tb, 1886. He had that day made thejourney to Swansea from Bridgend by rail. About two yearsbefore admission he severely strained himself in his work,and on the same night he felt a pain in the groin, which wasfollowed by swelling of the scrotum. He states that this

swelling was due to a rupture, and that he was able toreturn the bowel into the abdomen, but he never had anyadvice on the subject, and a truss which he applied and worefive months before his admission was of a very primitivenature. The wearing of this truss caused great pain,extending from the hip-bone to the seat of the aneurysm.He bore with this up to two months before admission, whenhe consulted a medical man, who immediately ordered himto bed. He states that," when lifting anything heavy, whenI had the truss on and my bowels came down, the beating

and pain was uuhearabie." ]To first noticed this pulsationone month after taking to the use of the instrument. lias

always been it great walker. Has never had syphilis. Hadacute rheumatism at the age of sixteen, and gonorrhoea atseventeen years of age. Is married. Is generally abstemious,and has never drank spirits. The family history is scanty.A sister died of phthisis pulmonalis.On admission there was a tense, pulsating tumour at the

upper and inner part of the right thigh, of irregular outlineand well elevated; it extended from Searpa’s triangle rightup to Poupart’s ligament, and thence to the side of thepubis. The impulse proceeding from it was eccentric. Theright leg was swollen throughout. Comparative measure-ments gave the following: Right thigh over tumour 23z in.,left 181 in. ; right thigh at Hunter’s canal 19} in., left151 in.; right knee 15} in., left 13 in. ; right calf 15 in.,lett 12.} in.; right instep 11 in., left 9} in. The patienthad suffered much pain of a continuous aching character,and extending along the right thigh from the anteriorsuperior spine of the ilium downwards to the outer side ofthe knee-joint. No pain at any time in the aneurysm. Noalbumen in the urine. The heart was free from any abnormalbruit. The temperature by the mouth on the evening ofSept. 8th was 101°.The external iliac artery was tied on Sept. 9th under

carbolic spray. The incision practised by Sir Astley Cooperwas made. The artery was ligatured with a double layerof No. 4 carbolised chromicised catgut, and the dressingsemployed were protective and gauze. His leg was thenbandaged with flannel over cotton-wool, and he was placedon a water-bed with the limb elevated and surrounded withhot-water bottles.The after-progress of the case was one of uninterrupted

recovery. No pulsation at any time again showed itself inthe aneurysm, and after a day or two all pain subsided.Ile was allowed to rise on Oct. 2Gth. The swelling in thelimb began to subside very quickly after the operation hadbeen performed, but it was found later on, on removing theflannel bandage, that two ulcers had formed on the outerside of the leg, no doubt from trophic nerve disturbance.They were situated over the peronei muscles at about themiddle of the limb, the upper one being half an inch inlength, and the lower one an inch and a half in length. Deep-seated suppuration and limited gangrene of the muscles atthat spot took place, and on Nov. 4th a rigor, with rise oftemperature to 10°°, took place; all this trouble was

immediately relieved by preventing the bagging of matter bymeans of carefully placed drainage-tubes. He was discharged

, on Dec. 6th, when the aneurysm sac was still to be felt as aI hard lump, absolutely devoid of impulse, and painless on

handling. The larger of the ulcers was still very slightly! open; the smaller ulcer had healed perfectly.

STAMFORD INFIRMARY.CALCULUS IN A BOY ; REMOVAL BY LATERAL

LITHOTOMY; CURE.

(Under the care of Dr. NEWMAN.)H. I-, aged thirteen, was admitted on Aug. 25th, 1885

A stunted, white, unhealthy lad. Is said to have had

symptoms of urinary irritation for a period of seven years.Constant incontinence, always in pain after passing urine.IIe has a long prepuce, with minute orifice.On Sept. 1st circumcision was performed, and the patient

sounded. A calculus of some size was readily struck.On Sept. 9hh lateral lithotomy was performed, usingChiene’s staff and a plain scalpel. The finger following theknife at once came on the stone, lying across the wound.This position was rectified, and the vesical wound enlargedwith a probe-pointed hernia knife. The stone was seizedwith a pair of small straight forceps (in its long diameter),and very slowly extracted. Little hemorrhage followed.The calculus was flattened, oval, and weighed 580 grains.Had not one bad symptom. On the fourth day urine waspassed per urethram. On the tenth day it was noted thatall the urine passed per urethram, and on the fourteenth daythe wound of the operation was perfectly healed. OnOct. 5th the lad went home quite well.

-Rem(irls.--Tlie case noted above seems to be worth puttingon record. The points of special interest are the long dura-tion of very severe symptoms, the size of the stone, and therapid repair of the surgical wound.

’