244

tended with meconium. After a day’s delay, to allow of

Igreater accumulation of fascal matter, having introduced thefinger into the anal passage, and feeling the fluctuation dis-tinctly, Mr. Athol Johnson passed a trocar by the side of hisfinger and introduced it into the tumour above. On with-drawing the trocar, about three ounces of perfectly clear andtransparent fluid, unmixed with blood or meconium, flowed ina full and rapid stream through the canula. The fluid lookedvery much like urine; but the child being a female, it was evi-dent that the bladder could not be in that position, and, onboiling, complete solidification took place, showing that it wasserum, and that it must have come from the distended peri-toneal cavity. The canula having been removed, and thefinger again introduced, no swelling could be detected; and asthe serous membrane evidently came down upon and partiallyinvested the cul-de-sac, it was not deemed expedient to makeany further attempt at reaching the bowel in that situation.In the afternoon of the same day, with the assistance of Mr.Holmes, Mr. Athol Johnson determined to perform Littre’soperation in the left groin. An incision was made a littleabove the level of the antero-superior spine of the ilium,nearly parallel with Poupart’s ligament, and the various partsdivided, until the peritoneum was reached. On opening this,a considerable quantity of serum escaped, and the sigmoidflexure presented itself at the wound, moderately distended ’,with meconium. This was secured to the edges of the incisionby sutures. and having been freely opened, a quantity of me-conium flowed out. No protrusion of the small intestines tookplace, and no amount of haemorrhage occurred. The child wasa little cold after the operation, but took some milk, &c., prettyfreely.The next day she was brought again, and appeared to be

going on well, taking the breast readily, and not having hadany sickness.On the evening of the following day, however, according to

the statement of the medical attendant, she got weaker, anddied without any marked symptoms of peritonitis.On examining the parts, peritonitis was found to be present

to some extent. The portion of intestine opened was the sig-moid flexure, a few inches before its termination in a blindextremity in the pelvis; this had been secured to the integu-ments, and no escape of meconium into the peritoneal cavityhad occurred. The sigmoid flexure and descending colon were,as is generally the case at this age, so completely surroundedby a meso colon, and so loosely attached to the parietes, thatit would have been impossible to have opened them in thelumbar region without wounding their serous covering. Thetermination of the rectum in the pelvis was at no great dis-tance from the anal passage, but the recto-vaginal pouch ofperitoneum descended unusually low in this case, investing therectum, as well as the upper surface of the anal cul-de-sac, tosuch an extent as to have rendered it almost impossible, espe-cially when the peritoneal cavity was distended with serum,to establish a free passage from the anus into the bowel above.This pouch had been punctured by the trocar, but the openinghad pretty well united, so that it was discovered with diffi-

culty.One or two points of interest will probably be noticed inthis case :-

1. The fact that, even if a fluctuating swelling is distinctlyfelt at the perinasum or in the anal orifice, it may arise notfrom the distended bowel, but from dropsy of the peritoneum,and consequently this membrane may be punctured.

2. That the peritoneum, perhaps in this case pushed downby the dropsical effusion, may descend so low as seriously tointerfere with operative treatment in this situation.

3. That the only other operation practicable in this case wasLittre’s operation in the groin; the post-mortem examinationshowing that an attempt to open the colon in the lumbarregion would have been attended with such difficulties as tooffer no chance of a successful result.

4. The incision having been made high up, rather above thelevel of the antero-superior spine, the bowel was reachedwithout any trouble.

ST. THOMAS’S HOSPITAL.THE RECENT CASE OF WOUND OF THE CAROTID ARTERY;

DETACHMENT OF THE LIGATURE.

(Under the care of Mr. LE GROS CLARK.)Tms interesting case, reported in a recent Mirror," has

thus far proceeded satisfactorily. The ligature placed uponthe common carotid came away on the 8th of February-six-

teen days after the operation. There has been no haemorrhage,and the man has gone on exceedingly well. We are glad tobe enabled to clear up a point in favour of the patient-viz.,that the severe wound of the neck was not self-made, butwas inflicted by an infuriated woman. Our remarks appertain-ing to the situation of the wound (ante, p. 141) will, therefore,apply to her, and not to the poor man himself.

Medical Societies.ROYAL MEDICAL & CHIRURGICAL SOCIETY.

TUESDAY, FEB. 28TH, 1860.

MR. F. C. SKEY, F.R.S., PRESIDENT.

ON A NEW METHOD OF EFFECTING THE RADICAL CUREOF HERNIA.

BY JOHN WOOD, F.R.C.S. ENG.,ASSISTANT-SURGEON TO KING’S COLLEGE HOSPITAL; DEMONSTRATOR IN

ANATOMY AT KING’S COLLEGE, LONDON; SURGEON TOTHE LINCOLN’S-INN DISPENSARY.

THE author commenced by a brief sketch of the anatomy ofthe tKMta 9’eMMt. The peculiarities of structure of the partsconcerned in inguinal hernia, of which especial advantage istaken in the operation proposed and practised by the author,are: 1st, the mobility and sliding power of the skin in thegroin, owing to the synovial character and loose areolar meshesof the deep layer of superficial fascia; 2nd, the total absenceof fat from the areolar tissue of the scrotum, its density, elas.ticity, toughness, and great vascularity enabling the surgeonto invaginate it into the inguinal canal, to retain it thereby stitches, and cause it permanently to adhere to its sides andto the cord; 3rd, the protection afforded to the peritoneumand vessels (epigastric and circumflex iliac) by the interven-tion of the fascia transversalis, and its connexion with thedeep surface of Poupart’s ligament; 4th, the formation by theconjoined tendon of the internal oblique and transversalis mus-cles and triangular ligament of the greater portion of the poste-rior wall of the canal, and the feasibility of raising the formerby the finger passed into the canal behind the lower edge ofthe internal oblique muscle, so as to pass a needle through itand the internal pillar of the external abdominal ring together.The author then stated that the methods respectively practisedby Ragg, Bonnet, Gerdy, and more lately by Wutzer of Bonn,and Rothemunde of Munich, most frequently fail in producing apermanent cure chiefly by their not obtaining a hold upon theposterior wall of the canal, and their securing only the anteriorportion of the fold produced by invagination, leaving the pos-terior half of the fold ready for the reception of a fresh portionof intestine. The objections to the introduction of a harddilating plug into the invaginated fold of skin and its retention,by Wutzer’s method, are as follows: that the skin and fasei2intervening in two layers between the compressing hard sur-faces and the serous laminae of the invaginated sac, ward offfrom them in great measure the effect intended,-namely, thatof adhesive inflammation; while the absence of counter-pressurebehind the posterior fold renders the dilating force of the plugalmost nugatory, unless sufficient expanding power to causesloughing be employed-to the great distress, not to say danger,of the patient. The dilating action of the plug upon the canaland external ring leaves the latter in a worse condition thanbefore in case of the failure of the operation. The principle ofplugging up a dilatable aperture like the inguinal opening issurely a false one. The invaginated skin invariably descendswhen the consolidation is absorbed, the latter being temporaryonly in its duration. The principle of the author’s operationis directly opposite to that of dilatation,-namely, that ofdrawing together and compressing the anterior and posteriorwalls of the canal in its whole length, and their union by theadhesive process with the invaginated fascia of the scrotum,which is detached from the skin and transplanted into thecanal, the skin being left to adhere below to the approximatedmargins of the external abdominal ring. By this means theposterior wall of the inguinal canal is made to act as a valveto prevent any future descent of the bowel, shutting up thesuperior opening by becoming united to the anterior wallthrough the medium of the scrotal fascia, which thus affords avery highly organized and vascular connective tissue betweenthe tendinous surfaces, which it would be very difficult tocause to adhere together otherwise. The fascial invagination