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A CASE OF POISONING BY NITROBENZOL.
88
Probably a preponderance of lymphocytes points to a slight irritation, and as such irritation is generally tuberculous it may be accepted as a proof of the tuberculous nature of the pleurisy. On the other hand, a large number of polymorphonuclear cells points to a more acute irritation of the pleura, and therefore indicates a tuberculous pleurisy of recent origin, or if found late a pleurisy of a different nature. In this connexion, however, we find contradictory statements. Thus, Gibson 16 of Edinburgh says that "the relative proportion of the leucocytes is an expression of the stage and extent of the reaction rather than a proof of the nature of its cause. During the early stages of all types the polymorphonuclear cells predominate, during the later stages the lymphocytes predominate." On the other hand, Hadley 17 stated at the British Medical Association meeting in 1905 that " the longer the effusion has been present the more polymorphonuclears there will be, so that even in tubercular cases of long standing the polymorphonuclear will be the more abundant cell. Indeed, a majority of lymphocytes go to prove tubercle, but a majority of polymorphonuclears does not prove the absence of tubercle if the case is of long standing. With regard to serous effusion in children, in whom rheu"
other of its varied manifestations is so as to whether some of these primary effusions are not possibly rheumatic in origin. The practical difficulty in the solution of this problem lies in the fact that while rheumatic pleurisy is common it tends to be fibrinoplastic in character and so rarely needs paracentesis. However, the first step has been taken, for Poynton and Paine 18 have found in pleural effusions the diplococcus associated with their names in cases of rheumatic polyserositis and have been able to produce rheumatic pleurisy matism in common a
one or
disease, the question arises
experimentally. Cytodiagnosis
will not assist in distinguishing a tuberculous from a rheumatic effusion, for in both cases it is the rule to find a preponderance of lymphocytes. In such cases, however, I have been helped by an examination of the blood, for while in tuberculous pleurisies a leucopenia is found a moderate amount of leucocytosis is the rule in rheumatic pleurisies.
Birmingham.
A CASE OF POISONING BY NITROBY A. H.
BENZOL. H. VIZARD, M.D. EDIN.,
STAFF
SURGEON, ROYAL NAVY.
CASES of poisoning by nitrobenzol, otherwise known as nitrobenzene, artificial oil of bitter almonds, essence of mirbane, are rare, and the following case which recently occurred at Bermuda may be of interest. The patient, a young white man, aged 21 years, employed as an engineer in a tug-boat, was brought to the dockyard surgery ab ut 2 P.M. on Oct. 12th in a collapsed and unconscious state, his two coloured companions stating that he had drunk some "acid"several hours previously and had had no medical assistance. I was immediately sent for and meanwhile he recovered consciousness, answering a few questions. Some lime-water had been given him before my arrival, the term "acid"being taken literally. When I saw the patient some ten minutes later I found him in an extreme state of collapse, with intense lividity of the face, but there were no signs of burning or charring Almost immediately he suddenly about the mouth. vomited profusely several pints of clear mucous fluid containing small particles of food. The adjacent wall and floor, together with his clothing, were covered with the vomited matter, and the atmosphere of the room instantly became charged with the odour of almonds from the The patient seemed relieved for a few minutes vomit. and was able to answer a few questions. He was so collapsed, however, that it was not considered advisable He was laid to make him vomit again immediately. in a recumbent position and covered up; brandy was given him by the mouth and strychnine hypodermically, 16
Gibson: Brit. Med. Jour., Jan. 7th, 1903. 17 Hadley: Ibid., Oct. 21st, 1905. Poynton and Paine: THE LANCET, Sept. 22nd (p. 861) and 29th (p. 932), 1900. 18
and hot water bottles were applied to his stomach and feet. He expectorated freely several times. The pulse, though rapid, became stronger, the breathing was a little more rapid than usual, but the extreme lividity of the face continued ; the skin was cool and the pupils were both widely dilated. About half an hour afterwards the pulse became weaker and irregular and as he could not swallow ether was injected hypodermically. No convulsions brandy occurred but the patient moaned occasionally and several times moved his hand towards his mouth. He gradually became comatose, although the pulse was quite perceptible, but about 3.50 P.M. the pulse suddenly ceased and in spite of hypodermic injections of ether he never recovered. From two companions employed in the same tug the following history was obtained. About 10.30 A.M. on that day the patient told one of them that he felt "bad," having swallowed some " rackarock oil" in mistake for whisky. He said he had taken three sips from the bottle, had swallowed the first two, but the last tasted strange so that he spat it out and made himself sick by putting his fingers down his throat. He said he had told no one about it and did not say at what time he had made the mistake. As he had been awakened that morning at 7 A.M., having slept on board the tug, and had had breakfast afterwards it is concluded that he must have taken the fluid with or after his breakfast, about 8 A.M. Apparently at 10.30 A.M. he did not feel very ill as the tug then started for the town of St. George’s, about 18 miles distant, to embark soldiers, and he drove the engines there. The time occupied in the journey was about oneind a half hours, and although he mentioned once or twice that he felt bad" he was well enough to make the tug race another steamboat part of the way. Towards the end of the journey he slept a little while and on reaching his destination he said that he felt well and did not want to see a medical man but went ashore to buy some food. The tug left St. George’s about three-quarters of an hour after aniving and he then ate some food-about 12.45 P.m. Half an hour afterwards he was found leaning against the reversing lever in the engine-room and collapsed on to the floor. He did not speak for about two minutes, but soon recovered and said that he felt all right, a-king for a feeding-can to oil the engines, which another man did for him, as he fell down when trying to mount a ladder. The odour of the so-called " acid " was observed by a companion and the patient said " that stuff is coming out all through me." At the second collapse a fireman noticed that his lips were blue and that there was some froth about them. Sbortly afterwards he collapsed again and did not speak; foorne soldiers assisted to get him on deck, where he remained till arriving in Grassy Bay, near the dockyard, about 2 P.:àL His companions managed to get him into a dinghy and rowed into the dockyard camber. He was carried to the surgery where I aw him about 2.15 P.M. I thought from the odour of the vomited matter and the external appearance of the patient that the so-called "acid"must be nitrobenzene and this was confirmed by a man in charge of blasting operations who said they used " oil of mirbane." This substance is added to an explosive substance, "rackarock,"before its use
in
blasting.
Remarks.-Nitrobenzol is described by Guy and Ferrier as an oily liquid of a pale yellow colour with an odour like bitter almonds. It is a powerful poison when inhaled or swallowed. The chief point of interest in this case is the of time that elapsed after swallowing the poison before serious symptoms of poisoning occurred, It was probably swallowed about 8 A.M., but the patient first mentioned its occurrence at 10.30 A.M. It was not until after 1 P.)!. that he became seriously ill, although at intervals between 10.30 A.M. and 1 p M. he said it was making him feel " bad." He was even able to make his tug race another steamboat on the way to St. George’s. At noon he evidently felt well enough to do some shopping and did not go to consult a medical man when he had the opportunity of so doing, so the poison must have been in his stomach four or five hours at least. After 1 P.M., when collapse first commenced, he was still able to talk about having taken the "oil"and to take an interest in his engines. The three attacks of collapse quickly followed each other and when seen the case appeared to be hopeless. This retardation of symptoms of poisoning is mentioned in the text-books and certainly was very marked in this case. Another feature was the extreme lividity of the face and the purple colour of the lips. The pupils were both widely dilated but became smaller shortly before death. The muscles were flexed, no
length
89 convulsions occurred, and death took cardiac failure.
place suddenly
from
in which loop of intestine is found outside the abdoI hernia minal cavity projecting into, and distending, the proximal
The poison is said to produce a burning sensation in the mouth. In this case it is remarkable that the mistake was unnoticed until the third mouthful had been taken, which the patient expectorated. He stated that he had made himself vomit but for four or five hours he must have had a considerable quantity of the poison in his stomach. He never described his sensations and only remarked after the second attack of collapse that " the stuff he drank was coming out all through him" and s’0 probably perceived the odour in his breath. Almost up to the time of his death he was able to answer questions. The free vomiting seemed temporarily to relieve him but the poison must have continued to act after the removal of the contents of the stomach. The bottle containing the fluid from which he had taken his draught had been thrown overboard when I sent for it. The reason why this fluid had been taken on board the tug was never discovered. Most of the symptoms observed follow closely the description of the poison given in the text-books, but I have been unable to find another case in which such a large quantity of this substance has been taken and in which serious symptoms have been delayed so long as four or five hours. Ireland Island, Bermudas.
STRANGULATION OF AN INFANTILE UMBILICAL HERNIA. BY PHILIP
TURNER, M.S. LOND., F.R.C.S ENG.,
ASSISTANT SURGEON TO
THE
BELGRAVE
HOSPITAL FOR CHILDREN, OF ANATOMY AT
CLAPHAM-ROAD, S.W. ; DEMONSTRATOR GUY’S HOSPITAL.
THE patient, a well-nourished child, aged 17 months, was taken to the out-patient department of the Belgrave Hospital for Children on June 22nd, 1905, with the following history. An umbilical hernia was noticed soon after birth but the protrusion was never great and it was always easily reducible by the mother. On the morning of June 21st the swelling was noticed to be larger than usual ; shortly after, the child, who previously had been in good health, was in great pain and she vomited 12 times in the 24 hours preceding admission. The bowels acted at 5 P.M. on the 21st after a dose of castor oil but no motion was passed between that hour and the time of admission, 11 A M. on the next day. The child then looked very ill, the pulse was 136, and the temperature was normal. Immediately beneath the umbilical scar was a tense swelling, measuring about two inches in length by one inch in breadth, and connected by a The skin covering it narrow pedicle to the abdominal wall. was stretched and bluish in colour and there was no impulse when the child cried. When the child was anaesthetised an unsuccessful attempt was made to reduce the hernia by taxis. An incision was then made and the sac, which was found to have a very narrow neck, was separdted from the surrounding tissues and then opened, allowing a quantity of odourless serous fluid to escape. No bowel was found but a piece of omcntum, which was discoloured and which showed a number of small petechise, was so tightly constricted at the neck of the sac that this had to be divided before any healthy omentum could be drawn from the abdominal cavity. The omentum was ligatured and removed, the sac was cut away, and the small gap in the abdominal wall was closed by silk stitches. There was no vomiting after the operation and the bowels acted in the evening of the same day. With the exception of some slight superficial suppuration convalescence was uneventful and the child was discharged with the wound healed on July 12th. She remained perfectly well until Nov. 30th when she was seen by Dr. 0. F. F. Grunbaum at the Belgrave Hospital for an attack of vomiting with constipation which it was thought might be due to some obstruction from adhesions following on the operation. She was admitted but the bowels acted well after an enema and she soon recovered and has remained perfectly well since. The scar is perfectly sound and there has been no protrusion since her
discharge last July. Three varieties of umbilical hernia may be distinguihed, of which two occur in children. 1. The congenital umbilical
a
of the umbilical cord. This, however, is not a truer hernia but is due to the persistence of the condition found in fcetal life before the third month where a loop of intestine developed from the mid-gut always projects well beyond the abdominal cavity. 2. The infantile umbilical hernia which is due to a yielding of the umbilical cicatrix and may appear very soon after birth. This variety of hernia undoubtedly tends to disappear as the child grows older and it is very unusual for it to persist till adult life. The third variety is the umbilical hernia of adults, which rarely appears before the age of 25 years. The congenital hernia usually contains a loop of ileum and usually a portion of colon with the cascum and appendix and, as might be expected from its development, a Meckel’s diverticulum when this structure is present. The infantile hernia usually contains omentum and frequently also a loop of ileum or colon. Strangulation of an umbilical hernia in a child is a rare I find that 79 cases of strangulated umbilical occurrence. hernia have been treated at Guy’s Hospital during the past 25 years. Of these 77 were in adults, the youngest patient being 33 years of age while two occurred in children, aged five days and one day respectively. These, however, were both cases of the congenital variety and though classified with strangulated hernias the trouble appeared to be, at any rate in part, due to sloughing of the coverings of the sac with subsequent peritonitis in the older child, while in the other the evidence of strangulation is doubtful. Both these children were operated on, the intestine being replaced, but in each case the child died. A number of similar cases have been recorded by Mr. W. G. Spencer1 and Mr. D’Arcy Powerwhile Mr. J. H. Riy3 records a case in which he was unable to return the loop of intestine to the abdominal cavity owing to the large size of the former and the small capacity of the latter. The loop of intestine was accordingly excised, but the child, who was only five days old, died from peritonitis. Indeed, when symptoms of obstruction have appeared in a congenital hernia the result is almost invariably fatal, the cause of death usually being peritonitis. In a number of cases, however, the intestine has been placed within the abdomen before any such symptoms have appeared with a successful result. The case which I have described, however, differs from these in that it was undoubtedly an infantile umbilical hernia, and strangulation of this form of hernia is a very rare occurrence. I can suggest no reason why it should have occurred except that the neck of the sac was extremely narrow, not more than one-third of an inch in diameter, and the margin of the ring very sharp. There was no point of interest about the actual operation, but it was satisfactory to find that in spite of the suppuration there had been no recurrence of the hernia five and a half months afterwards. St. Thomas’s-street, S.E.
part
TWO CASES ILLUSTRATING SCIATICA OF ABDOMINAL ORIGIN; LAPAROTOMY. BY F. W. FORBES-ROSS, M.D.EDIN., F.R.C.S. ENG. LATE CLINICAL
ASSISTANT; SAMARITAN HOSPITAL, LONDON.
THE two following cases are interesting and are recorded, not so much from the standpoint of the actual lesions themselves as for the remote conditions to which they gave iise. The cause of the sciatica in both instances was only recognised when other subsequent, independent, and direct symptoms (apart from sciatica) drew attention to, and caused the sufferers to seek advice for, a condition of affairs existing within the abdominal cavity which had not hitherto been suspected as giving rise to the nervous affection. The first case is one illustrative of what may be called the true sensory physiological reflex nervous response of one spinal segment to peripheral irritation existing in the area supplied by another adjacent spinal segment. Ovarian reflex pain was ably handled by Dr. G. Ernest Herman in his address to the Gynaecological Section of the 1 Transactions of the
vol. 3
Pathological Society 2
of
London, vol. xlix.
Ibid., vol. xxxix.
Proceedings ii.
of the
Society
for the
Study of Diseases
of
Children,
Probably a preponderance of lymphocytes points to a slight irritation, and as such irritation is generally tuberculous it may be accepted as a proof of the tuberculous nature of the pleurisy. On the other hand, a large number of polymorphonuclear cells points to a more acute irritation of the pleura, and therefore indicates a tuberculous pleurisy of recent origin, or if found late a pleurisy of a different nature. In this connexion, however, we find contradictory statements. Thus, Gibson 16 of Edinburgh says that "the relative proportion of the leucocytes is an expression of the stage and extent of the reaction rather than a proof of the nature of its cause. During the early stages of all types the polymorphonuclear cells predominate, during the later stages the lymphocytes predominate." On the other hand, Hadley 17 stated at the British Medical Association meeting in 1905 that " the longer the effusion has been present the more polymorphonuclears there will be, so that even in tubercular cases of long standing the polymorphonuclear will be the more abundant cell. Indeed, a majority of lymphocytes go to prove tubercle, but a majority of polymorphonuclears does not prove the absence of tubercle if the case is of long standing. With regard to serous effusion in children, in whom rheu"
other of its varied manifestations is so as to whether some of these primary effusions are not possibly rheumatic in origin. The practical difficulty in the solution of this problem lies in the fact that while rheumatic pleurisy is common it tends to be fibrinoplastic in character and so rarely needs paracentesis. However, the first step has been taken, for Poynton and Paine 18 have found in pleural effusions the diplococcus associated with their names in cases of rheumatic polyserositis and have been able to produce rheumatic pleurisy matism in common a
one or
disease, the question arises
experimentally. Cytodiagnosis
will not assist in distinguishing a tuberculous from a rheumatic effusion, for in both cases it is the rule to find a preponderance of lymphocytes. In such cases, however, I have been helped by an examination of the blood, for while in tuberculous pleurisies a leucopenia is found a moderate amount of leucocytosis is the rule in rheumatic pleurisies.
Birmingham.
A CASE OF POISONING BY NITROBY A. H.
BENZOL. H. VIZARD, M.D. EDIN.,
STAFF
SURGEON, ROYAL NAVY.
CASES of poisoning by nitrobenzol, otherwise known as nitrobenzene, artificial oil of bitter almonds, essence of mirbane, are rare, and the following case which recently occurred at Bermuda may be of interest. The patient, a young white man, aged 21 years, employed as an engineer in a tug-boat, was brought to the dockyard surgery ab ut 2 P.M. on Oct. 12th in a collapsed and unconscious state, his two coloured companions stating that he had drunk some "acid"several hours previously and had had no medical assistance. I was immediately sent for and meanwhile he recovered consciousness, answering a few questions. Some lime-water had been given him before my arrival, the term "acid"being taken literally. When I saw the patient some ten minutes later I found him in an extreme state of collapse, with intense lividity of the face, but there were no signs of burning or charring Almost immediately he suddenly about the mouth. vomited profusely several pints of clear mucous fluid containing small particles of food. The adjacent wall and floor, together with his clothing, were covered with the vomited matter, and the atmosphere of the room instantly became charged with the odour of almonds from the The patient seemed relieved for a few minutes vomit. and was able to answer a few questions. He was so collapsed, however, that it was not considered advisable He was laid to make him vomit again immediately. in a recumbent position and covered up; brandy was given him by the mouth and strychnine hypodermically, 16
Gibson: Brit. Med. Jour., Jan. 7th, 1903. 17 Hadley: Ibid., Oct. 21st, 1905. Poynton and Paine: THE LANCET, Sept. 22nd (p. 861) and 29th (p. 932), 1900. 18
and hot water bottles were applied to his stomach and feet. He expectorated freely several times. The pulse, though rapid, became stronger, the breathing was a little more rapid than usual, but the extreme lividity of the face continued ; the skin was cool and the pupils were both widely dilated. About half an hour afterwards the pulse became weaker and irregular and as he could not swallow ether was injected hypodermically. No convulsions brandy occurred but the patient moaned occasionally and several times moved his hand towards his mouth. He gradually became comatose, although the pulse was quite perceptible, but about 3.50 P.M. the pulse suddenly ceased and in spite of hypodermic injections of ether he never recovered. From two companions employed in the same tug the following history was obtained. About 10.30 A.M. on that day the patient told one of them that he felt "bad," having swallowed some " rackarock oil" in mistake for whisky. He said he had taken three sips from the bottle, had swallowed the first two, but the last tasted strange so that he spat it out and made himself sick by putting his fingers down his throat. He said he had told no one about it and did not say at what time he had made the mistake. As he had been awakened that morning at 7 A.M., having slept on board the tug, and had had breakfast afterwards it is concluded that he must have taken the fluid with or after his breakfast, about 8 A.M. Apparently at 10.30 A.M. he did not feel very ill as the tug then started for the town of St. George’s, about 18 miles distant, to embark soldiers, and he drove the engines there. The time occupied in the journey was about oneind a half hours, and although he mentioned once or twice that he felt bad" he was well enough to make the tug race another steamboat part of the way. Towards the end of the journey he slept a little while and on reaching his destination he said that he felt well and did not want to see a medical man but went ashore to buy some food. The tug left St. George’s about three-quarters of an hour after aniving and he then ate some food-about 12.45 P.m. Half an hour afterwards he was found leaning against the reversing lever in the engine-room and collapsed on to the floor. He did not speak for about two minutes, but soon recovered and said that he felt all right, a-king for a feeding-can to oil the engines, which another man did for him, as he fell down when trying to mount a ladder. The odour of the so-called " acid " was observed by a companion and the patient said " that stuff is coming out all through me." At the second collapse a fireman noticed that his lips were blue and that there was some froth about them. Sbortly afterwards he collapsed again and did not speak; foorne soldiers assisted to get him on deck, where he remained till arriving in Grassy Bay, near the dockyard, about 2 P.:àL His companions managed to get him into a dinghy and rowed into the dockyard camber. He was carried to the surgery where I aw him about 2.15 P.M. I thought from the odour of the vomited matter and the external appearance of the patient that the so-called "acid"must be nitrobenzene and this was confirmed by a man in charge of blasting operations who said they used " oil of mirbane." This substance is added to an explosive substance, "rackarock,"before its use
in
blasting.
Remarks.-Nitrobenzol is described by Guy and Ferrier as an oily liquid of a pale yellow colour with an odour like bitter almonds. It is a powerful poison when inhaled or swallowed. The chief point of interest in this case is the of time that elapsed after swallowing the poison before serious symptoms of poisoning occurred, It was probably swallowed about 8 A.M., but the patient first mentioned its occurrence at 10.30 A.M. It was not until after 1 P.)!. that he became seriously ill, although at intervals between 10.30 A.M. and 1 p M. he said it was making him feel " bad." He was even able to make his tug race another steamboat on the way to St. George’s. At noon he evidently felt well enough to do some shopping and did not go to consult a medical man when he had the opportunity of so doing, so the poison must have been in his stomach four or five hours at least. After 1 P.M., when collapse first commenced, he was still able to talk about having taken the "oil"and to take an interest in his engines. The three attacks of collapse quickly followed each other and when seen the case appeared to be hopeless. This retardation of symptoms of poisoning is mentioned in the text-books and certainly was very marked in this case. Another feature was the extreme lividity of the face and the purple colour of the lips. The pupils were both widely dilated but became smaller shortly before death. The muscles were flexed, no
length
89 convulsions occurred, and death took cardiac failure.
place suddenly
from
in which loop of intestine is found outside the abdoI hernia minal cavity projecting into, and distending, the proximal
The poison is said to produce a burning sensation in the mouth. In this case it is remarkable that the mistake was unnoticed until the third mouthful had been taken, which the patient expectorated. He stated that he had made himself vomit but for four or five hours he must have had a considerable quantity of the poison in his stomach. He never described his sensations and only remarked after the second attack of collapse that " the stuff he drank was coming out all through him" and s’0 probably perceived the odour in his breath. Almost up to the time of his death he was able to answer questions. The free vomiting seemed temporarily to relieve him but the poison must have continued to act after the removal of the contents of the stomach. The bottle containing the fluid from which he had taken his draught had been thrown overboard when I sent for it. The reason why this fluid had been taken on board the tug was never discovered. Most of the symptoms observed follow closely the description of the poison given in the text-books, but I have been unable to find another case in which such a large quantity of this substance has been taken and in which serious symptoms have been delayed so long as four or five hours. Ireland Island, Bermudas.
STRANGULATION OF AN INFANTILE UMBILICAL HERNIA. BY PHILIP
TURNER, M.S. LOND., F.R.C.S ENG.,
ASSISTANT SURGEON TO
THE
BELGRAVE
HOSPITAL FOR CHILDREN, OF ANATOMY AT
CLAPHAM-ROAD, S.W. ; DEMONSTRATOR GUY’S HOSPITAL.
THE patient, a well-nourished child, aged 17 months, was taken to the out-patient department of the Belgrave Hospital for Children on June 22nd, 1905, with the following history. An umbilical hernia was noticed soon after birth but the protrusion was never great and it was always easily reducible by the mother. On the morning of June 21st the swelling was noticed to be larger than usual ; shortly after, the child, who previously had been in good health, was in great pain and she vomited 12 times in the 24 hours preceding admission. The bowels acted at 5 P.M. on the 21st after a dose of castor oil but no motion was passed between that hour and the time of admission, 11 A M. on the next day. The child then looked very ill, the pulse was 136, and the temperature was normal. Immediately beneath the umbilical scar was a tense swelling, measuring about two inches in length by one inch in breadth, and connected by a The skin covering it narrow pedicle to the abdominal wall. was stretched and bluish in colour and there was no impulse when the child cried. When the child was anaesthetised an unsuccessful attempt was made to reduce the hernia by taxis. An incision was then made and the sac, which was found to have a very narrow neck, was separdted from the surrounding tissues and then opened, allowing a quantity of odourless serous fluid to escape. No bowel was found but a piece of omcntum, which was discoloured and which showed a number of small petechise, was so tightly constricted at the neck of the sac that this had to be divided before any healthy omentum could be drawn from the abdominal cavity. The omentum was ligatured and removed, the sac was cut away, and the small gap in the abdominal wall was closed by silk stitches. There was no vomiting after the operation and the bowels acted in the evening of the same day. With the exception of some slight superficial suppuration convalescence was uneventful and the child was discharged with the wound healed on July 12th. She remained perfectly well until Nov. 30th when she was seen by Dr. 0. F. F. Grunbaum at the Belgrave Hospital for an attack of vomiting with constipation which it was thought might be due to some obstruction from adhesions following on the operation. She was admitted but the bowels acted well after an enema and she soon recovered and has remained perfectly well since. The scar is perfectly sound and there has been no protrusion since her
discharge last July. Three varieties of umbilical hernia may be distinguihed, of which two occur in children. 1. The congenital umbilical
a
of the umbilical cord. This, however, is not a truer hernia but is due to the persistence of the condition found in fcetal life before the third month where a loop of intestine developed from the mid-gut always projects well beyond the abdominal cavity. 2. The infantile umbilical hernia which is due to a yielding of the umbilical cicatrix and may appear very soon after birth. This variety of hernia undoubtedly tends to disappear as the child grows older and it is very unusual for it to persist till adult life. The third variety is the umbilical hernia of adults, which rarely appears before the age of 25 years. The congenital hernia usually contains a loop of ileum and usually a portion of colon with the cascum and appendix and, as might be expected from its development, a Meckel’s diverticulum when this structure is present. The infantile hernia usually contains omentum and frequently also a loop of ileum or colon. Strangulation of an umbilical hernia in a child is a rare I find that 79 cases of strangulated umbilical occurrence. hernia have been treated at Guy’s Hospital during the past 25 years. Of these 77 were in adults, the youngest patient being 33 years of age while two occurred in children, aged five days and one day respectively. These, however, were both cases of the congenital variety and though classified with strangulated hernias the trouble appeared to be, at any rate in part, due to sloughing of the coverings of the sac with subsequent peritonitis in the older child, while in the other the evidence of strangulation is doubtful. Both these children were operated on, the intestine being replaced, but in each case the child died. A number of similar cases have been recorded by Mr. W. G. Spencer1 and Mr. D’Arcy Powerwhile Mr. J. H. Riy3 records a case in which he was unable to return the loop of intestine to the abdominal cavity owing to the large size of the former and the small capacity of the latter. The loop of intestine was accordingly excised, but the child, who was only five days old, died from peritonitis. Indeed, when symptoms of obstruction have appeared in a congenital hernia the result is almost invariably fatal, the cause of death usually being peritonitis. In a number of cases, however, the intestine has been placed within the abdomen before any such symptoms have appeared with a successful result. The case which I have described, however, differs from these in that it was undoubtedly an infantile umbilical hernia, and strangulation of this form of hernia is a very rare occurrence. I can suggest no reason why it should have occurred except that the neck of the sac was extremely narrow, not more than one-third of an inch in diameter, and the margin of the ring very sharp. There was no point of interest about the actual operation, but it was satisfactory to find that in spite of the suppuration there had been no recurrence of the hernia five and a half months afterwards. St. Thomas’s-street, S.E.
part
TWO CASES ILLUSTRATING SCIATICA OF ABDOMINAL ORIGIN; LAPAROTOMY. BY F. W. FORBES-ROSS, M.D.EDIN., F.R.C.S. ENG. LATE CLINICAL
ASSISTANT; SAMARITAN HOSPITAL, LONDON.
THE two following cases are interesting and are recorded, not so much from the standpoint of the actual lesions themselves as for the remote conditions to which they gave iise. The cause of the sciatica in both instances was only recognised when other subsequent, independent, and direct symptoms (apart from sciatica) drew attention to, and caused the sufferers to seek advice for, a condition of affairs existing within the abdominal cavity which had not hitherto been suspected as giving rise to the nervous affection. The first case is one illustrative of what may be called the true sensory physiological reflex nervous response of one spinal segment to peripheral irritation existing in the area supplied by another adjacent spinal segment. Ovarian reflex pain was ably handled by Dr. G. Ernest Herman in his address to the Gynaecological Section of the 1 Transactions of the
vol. 3
Pathological Society 2
of
London, vol. xlix.
Ibid., vol. xxxix.
Proceedings ii.
of the
Society
for the
Study of Diseases
of
Children,