482

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

ST. BARTHOLOMEW’S HOSPITAL.Hernia and Perforated Intestine.

(Under the care of Mr. LLOYD.)

THE subject of this case, a woman about thirty, was broughtto the hospital with the symptoms of strangulated crural

hernia on the left side, and placed under the care of Mr.Lloyd, Jan. 29th, 1850. The hernia, for which she had neverworn any truss, was reduced by the house-surgeon, and shehad, soon afterwards, two alvine evacuations. The next

morning, however, the hernia came down again, the patientfell into a low, typhoid state, and tympanitis came on. The

protrusion was again reduced; but as the symptoms increased,and a small tumour could be felt in the crural region, on theleft side, Mr. Lloyd, with the concurrence of some of his col-leagues, though in doubt as to the results, resolved upon ope-rating.The integuments were slit open, in a longitudinal direction,

exactly over the swelling; various layers were divided uponthe director, and the tumour was found not to be largerthan a pigeon’s egg. Gimbernat’s ligament was then divided,external to the sac, in the usual way, but the best-directedefforts could not succeed in returning the hernia. Mr. Lloydwas then compelled to open the sac; and upon doing this, alightish fluid gushed out, which had very much the smell offæculent matter.An idea was at first entertained, when the light colour of

the fluid was observed, that the tumour might be connectedwith the bladder; but Mr. Lloyd soon came to the conclusionthat this was a case of perforated intestine, that the contentsof the bowels had escaped into the abdomen, and that thesac was filled with part of the effused fluid. It was nowevident that the patient’s chance of recovery was very small;in fact, Mr. Lloyd had stated, before the operation, that hesuspected the case to be one of perforated intestine, and thathe was induced to operate, rather from a sense of duty, thanwith much hope of saving the patient. The latter was verymuch distressed during the operation, vomited abundantly,and had very tense tympanitis. The small, protruded knucklewas, however, returned, and the wound left open, with a pieceof omentum lying in it.Mr. Lloyd mentioned that he had had a case of perforation,

some time ago, where the opening was luckily situated in theprotruded intestine. He enlarged that opening, and thewoman recovered perfectly, after having had artificial anus inthe groin for some time. In fact, Mr. Lloyd has had no lessthan three cases of a very similar description, all of whichhave done well. In two of the cases considerable portionsof intestine sloughed, and yet recovery took place. The

principal means employed were, daily injections of warmwater into the rectum, so as to keep up freedom of actionand transit in the part. As to the wound in the groin, nothingbut poultices were used at first, and simple dressing after-wards.The subject of the present operation died the next day, and,

unfortunately, no post-mortem examination could be obtained.

GUY’S HOSPITAL.Fracture of the Tibia.

(Under the care of Mr. HILTON

Mr. Hilton is on the eve of discharging from his wards ayoung man, who, about the 1st of March, had fallen from aheight, and alighted on his feet. The force of the fall ex-pended itself on the left leg, where the tibia, fibula, andastragalus were completely fractured, with protrusion of thefirst of these bones. The destruction of parts was so great,that the only course left for Mr. Hilton to adopt was amputa-tion of the leg. It was therefore taken off, soon after thepatient’s admission, by the circular operation, the flapsbeing brought together by lateral compression. The patient

has since done extremery weil. we wish w uruw eajaeuaaiattention to an experiment which Mr. Hilton took occasionto perform on the pathological specimen.

The preparation, as shown to the pupils by Mr. Hilton,presented a good example of fracture of both bones, withprotrusion of the tibia; the astragalus was likewise broken;the tendons, both of the tibialus anticus, extensor digitorum,and peroncsi muscles, were not much displaced; and theanterior tibial artery was severed on a level with the brokenend of the tibia.

On. this artery Mr. Hilton performed a very interestingexperiment. He introduced the pipe of a syringe into theupper part of the vessel-viz., the extremity through whichthe amputating knife had run-and driving some water intoit, the stream was stopped at the lower end of the vessel,which was completely closed. Now this was a clear proofthat the clot or internal coagulnm plugging up the orifice ofthe artery had been formed in a very short time, no trace ofthe external coagulum being left in the cellular tissue around,and it showed that the retraction of the coats of the vessel,and the internal fibrinous deposit, had effected its completeobliteration. This circumstance was confirmed by slitting openthe artery from above downwards. At a little distance fromthe lower extremity the commencement of the little fibrinouscone was easily perceived, the end of the vessel being com-pletely closed by its base. Mr. Hilton then tried whether theobstacle could be forced out by driving the water into theartery with great power; but it resisted pretty strong efforts.The patient will soon be discharged, with a very good

stump. ____

ST. THOMAS’S HOSPITAL.

Crural Hernia.

(Under the care of Mr. SIMON.)

The mortality after operation for hernia might at first sightappear large in hospital practice, but when we consider, thatpatients afflicted with such displacement, and who suddenlysuffer from strangulation, apply in general very late for relief;that before they present themselves numerous attempts at thetaxis are usuallymade; that the handling they undergo is mostlyof a rough kind; and that the constitution is often unable tobear the shock of the strangulation and the operation, from pre-vious intemperate habits-we should be slow in ascribing fatalresults to the operation itself, as the patient’s friends are tooapt to do. It likewise may happen in certain cases, of whichthe following is a very striking instance, that an intercurrentdisease may carry off the patient when we are harbouringthe hope that we have saved life by timely surgical interfer-ence.

Charlotte P-, sixty-six years of age, following the occu-pation of charwoman, was admitted under the care of Mr.Simon, with symptoms of strangulated hernia, Jan. 22nd, 1850.Patient has had fifteen children, and has suffered from pro-lapsus uteri for nine years; she states that eight years ago,while lifting a large pail full of water, she felt something snapwithin her, and soon afterwards perceived a small swelling inthe left groin, about the size of a walnut. (It appears ex-tremely probable that in those sudden cases where somethingis said to have snapped unexpectedly, a knuckle of intestineor a piece of omentum has been for some time engaged in thering, and that the effort usually looked upon as having beenthe cause of the hernia, is merely coincident with its fulldevelopment.)From this period the swelling gradually increased in size,

but did not prevent her from following her occupation,nor gaveher anyparticular pain. The protrusion was never reduced,andthe patient wore no truss, nor had any medical advice. Fivedays before admission, the swelling suddenly increased in sizeafter an attack of diarrhoea., accompanied by severe tenes-mus, it became painful, nausea and vomiting set in, and thebowels were obstinately constipated.On admission the patient complained of pain in the left

hypogastric region, extending to the umbilicus; the pain wasincreased on pressure, and accompanied with nausea and occa-sional vomiting; the bowels, as above stated, had been confinedfor the last five days; the tongue was white, the skin dry, andthe thirst very great. On examination, an ovoid tumour,larger than a man’s fist, was observed in the upper and innerpart of the left thigh, its base being directed upwards abovePoupart’s ligament. The swelling, was painful, tense, andelastic; the taxis was tried for a short time, but without suc-cess, and an enema of castor oil was administered. The in-jection brought away a small quantity of scybalous matter,but the symptoms became more and more alarming, and the