A CASE OF STRANGULATED FEMORAL AND OBTURATOR HERNIÆ.

744 oil &c., and, after a hypodermic injection of apomorphia had failed to act, a soft ooaophageal tube was passed in order to empty the stomach ; this, however, could not be effected on account of the openings in the tube becoming plugged. About fifteen minutes after the exhibition of the and while the tube was being manipulabed, the patient vomited, bringing up about a pint and a half of lightbrown, curdy, tenacious material containing lumps of apparently partially digested food. This at the time was supposed to be the remains of a recent meal, and unfortunately was not preserved. Great difficulty was found in soothing the patient and in overcoming the effects of shock; but he eventually made a good recovery, and was able to leave the hospital thirteen days after his admission. The mouth was still somewhat sore, but he could swallow without difficulty. Two months later, when seen at the Quarter Sessions, he was apparently quite free from the effects of the poison. On account of his mental condition he was handed over to the care of his friends, and, as the police have not heard anything of him since, ib is to be presumed that he has had no further trouble. The history of the attempt on his life, as received from the man himself and from others, is as follows :-He had been out of work for some time, and for several months had suffered from mental depression and hallucinations, imagining that his dead wife frequently appeared to him, upbraiding him for previous cruelty, although, according to the account of his neighbours, he had always been a good husband. Four months previously to this date he determined to do away and for this purpose procured three ounces of with but, changing his mind, he carefully put strong it asideforfutiure use. On Aug. 21st, his hallucinations having ’become more persistent, he decided to take the poison. After a light meal of bread and tea at about 5.30 P.M., he spent the evening and greater part of the night in removing his few belongings, piecemeal, to a friend’s house at some distance from his own. This had to be done very warily, on account of the police, who, as he remarked, "might have asked questions." At 5 A.M., having completed this job, he up a friend in order to bid him good-bye. This friend, knowing the man to be a " bit strange in his head," talked soothingly to him, and, having advised him " not to do anything foolish," regaled him with a cup of tea and a slice of bread-and-butter, and, on starting for his work at 5.45 A M., left him asleep in a chair. Shortly after 6 A.M. the patient awakened and went back to his own house, where he finished his preparations by placing the bobble of poison on a chair, rolling up his coat to act as a cushion, and putting it against the wall close by, and writing his last instructions on a piece of paper which he on the pinned to his waistcoat. Then, seating himself floor so that he could lean against the coat, he " took the cork out of the bottle, put the neck well into his mouth, so He says he as not to burn his lips, and took a good swig." became unconscious almost immediately, but he evidently had time to re-cork the bottle and replace it on the chair, for there it was subsequently found. All this must have occurred at about 6.30A.M., and the man was not discovered

A CASE OF STRANGULATED FEMORAL AND

OBTURATOR HERNIÆ. BY A. R. ANDERSON, F.R.C.S.,

apomorphia,

SURGEON TO THE GENERAL

HOSPITAL, NOTTINGHAM.

JANE S-,aged seventy-five, was admitted into the Nottingham General Hospital on Oct. 3rd, 1891, for a strangulated hernia in the left groin. She stated that for many years she had noticed a small lump, the size of a nut, in the groin, which had given her no trouble until two days before admission, when it had suddenly got much larger, and she thereupon began to complain of pain in the part, accompanied by vomiting and constipation. There had been no action of the bowels since the descent took place, but she said that she had been able to pass flatus. On examination of the left groin a lump the size of an orange was seen, which had evidently come through the saphenous opening. It was rounded in outline, firm, and very tender on manipulation. There was no impulse on coughing, and dulness on percussion. She was admitted at 6 P.M., and at 7.30 I paw her and operated, after failure of the taxis, under chloroform. On opening the sac a lump of omentum was found projecting through the saphenous opening, the neck of which was very tightly constricted at Gimbernat’s ligament. This was notched, and the omentum drawn down and examined. It did not appear to be much damaged, and was reduced. No bowel was found. I then passed a finger through the inner ring and felt around it, satisfying myself that all was clear. The wound was closed with horsehair sutures and a dressing of mercurial wool applied. The operation lasted only a few minutes. The next morning (Oct. 4th) she had passed a fairly good night, and seemed decidedly better. She had been sick twice shortly after the operation, the vomited matter consisting simply of the contents of the stomach. I attributed the vomiting to the chloroform. An enema was then ordered, which was followed by an evacuation of faeces. On the following morning, however, she became rather suddenly worse and began rapidly to go down hill, unmistakable faecal vomiting appeared, and on seeing her some hours later she presented the aspect of a person in the latter stages of an unrelieved strangulated hernia. At this time she passed another motion. As it now appeared evident from the presence of these symptoms that there must be some unrelieved obstruction,I decided to explore further. Nothing could be discovered on examination of the groin, and being satisfied that there was nothing in the femoral canal, and failing to find a hernia elsewhere, I decided to open the abdomen. A median incision three inches and a half long was made in the linea alba below the umbilicus, and on introducing the hand I found that a knuckle of small intestine (ileum) had passed through the left obturator foramen and was there strangulated. The portion of bowel included was very tightly nipped by the sharp edge of the obturator membeneath which the edge of a hernia knife was brane, till 1.30 P.M. From inquiries made there is every reason to considerable difficulty, and the membrane after passed believe that the bottle originally contained three ounces of notched in a downward direction. The bowel was ganthe acid, and afterwards there was found in it just short An examinaon being withdrawn. and grenous, gave way of two ounce?. None of it had been spilled on the floor, of the parts outside the abdomen showed that the whole tion fluid of was the chair, or on the patient’s clothes. The of the circumference of the bowel had not been included, colour of light portwine, quite clear, and of sp. gr. 1065 ; and that the gangrene had involved a portion of the inI who and was assured by Dr. Stevenson of Guy’s Hospital, testine, measuring two inches in length, but implicating kindly examined it for me, that it consisted of the strong only two-thirds of its circumference. A pair of Makins’ acid. liquefied were at once applied, which effectually prevented clamps In this case it seems to be quite possible-nay, probableof the intestinal contents, the length of ganthat while the man was making his elaborate destructive any escape bowel and the divided ends joined grenous preparations the stomach, by reflex action, was equally em- together by meansexcised, of Lembert sutures. On removal of the on a out a large protective process-viz., pouring ployed the intestinal contents flowed freely past the line of supply of mucus, on which, when ingested, the acid chiefly clamps suture and demonstrated its security. The abdominal acted. If this were not so, how can the thick, tenacious wound was closed in the usual way. The patient, who was contents of the stomach be accounted for? Both the patient andhis friend agreed that he had eaten only one slice of in a very unsatisfactory state at the time of the operation, bread-and-butter in the morning, and the last food he had did not rally, and died some hours afterwards. On a subsequent examination of the parts there was no leakage had before this was some bread twelve hours previously. whatever from the sutured bowel, the opening in the Surbiton. obturator membrane admitted the forefinger, the femoral

laim

carbolic acid

knocked

THE MAGISTRACY

the recom mendation of the Lord-Lieutenant of the county the Righ

(IRELAND).—On

Hon. the Lord Chancellor has appointed W. Langford Symes, Esq., L.R.C.P. &c., of Kiltegan, to the Commissioi of the Peace for the county of Wicklow.

canal was empty, and there was nothing wrong with the lump of omentum which had been reduced. The obturator vessels and nerve passed through the foramen above and

external to the

sac.

appears to be worth recording on account of its clinical importance, as well as of the extreme rarity of the This

case

745

simultaneous occurrence of these two herniæ, and a critical bark, dialysed iron, brandy, and champagne, but with very examination of the symptoms presented may be of interest. little benefit. For two weeks she continued in much the

small same condition, now showing slight improvement, again by pain relapsing, but making no decided progress towards recovery. in the part, vomiting, and constipation. 1. With respect On Feb. 23rd choreic movements began in the fingers of the to the swelling, this entirely disappeared after the reduction right hand, and three days later all the muscles of the arm of the femoral epiplocele. At the time of the second opera- and face had become involved. The arm was jerked about tion the parts about the saphenous opening were carefully so violently that it was found necessary to secure it, the broken in places. Her speech was much iminspected, and no swelling of any kind existed at or about skin being the situation in which an obturator hernia is known to pro- paired, and she had to be fed from a feeding cup. Liquor trude ; indeed, as was afterwards shown, the knuckle of gut arsenicalis was given, and she was put on milk, liquor involved in the obturator foramen was too small to produce carnis, peptonoids, peptonised cocoa and milk, brandy, this sign. 2. The question as to whether the special pain and port wine. On the morning of March 6th the existed along the course of the obturator nerve that is movements had enoirely ceased, leaving the patient in a usually met with in these cases must remain doubtful. No very exhausted condition, from which she never rallied ; uaquiry was made as to such pain (the disease not being sus- she grew gradually weaker, and died on Marchllth. In pected), and no complaint was made of it. It is reasonable to her youth she had an attack of diphtheria, followed by suppose, however, that, if present, it was not severe, as she paralysis of the right arm, lasting some months. complained greatly on admission of pain referred to the region Kempsey, Worcester. of the groin and nowhere else, and the morning after the first operation expressed herself as being free from pain. 3. With PHLEGMASIA DOLENS FOLLOWING INFLUENZA. regard to the vomiting, no accurate information could be BY C. ALEX. DUCKET, M.R.C.S. obtained about this symptom prior to admission beyond the fact that it had occurred, and the patient was not sick I in the interval which elapsed between her admission into ’ ALTHOUGH phlegmasia dolens is a disease which occurs the hospital and the time of the first operation. It should chiefly in the puerperal state, I have seen it lately in three also be noted that the vomiting which occurred twice after cases of influenza, all of which bore striking resemblance to this operation, and which I attributed to the effects of the other. Instead of the temperature going down, as is each anaesthetic, was absolutely non-feculent in character, conin usual an uncomplicated case, it kept up. There was listing simply of the contents of the stomach, feculent in the groin and upper part of the thigh, on the second after ’vomiting appearing suddenly day opera- great pain tion. 4. The constipation, it will be remembered, was quickly followed by swelling, which extended over the not absolute. Although there had not been any movement whole limb. This rapidly increased, so that in two days of the bowels for forty-eight hours previous to admission, the limb was twice as large as the non-affected one. The yet she had during that time passed flatus, and continued swelling was of a very solid nature, and did not pit upon to do so on the day after operation. At this time her pressure. There was not the least alteration by raising bowels were well moved after an enema, and there was the leg. This state of things lasted for ten days, under the another slight motion on the following day. All these usual treatment, when the pain grew less, the limb softer, anomalous symptoms, which made me doubt at the time and the temperature fell to 998°. All three patients were that there was anything more than the severely constricted affected in the left lower extremity, and were very restless. ’8piploeele to account for them, were probably caused by the The obstructed vessels could be easily felt as hard cords. fact that a portion of the calibre of the intestine had escaped I may mention that the above pabients were not subject to strangulation and had allowed flatus and some liquid fseoes varicose veins, and, although married women with families, to pass. Death resulted in this case from the inability of were never before troubled with their legs. The frequency an aged and feeble person to bear the shock of the second of phlegmasia dolens in the lying-in period is attributed to operation; excepting for this, no reason was disclosed at the the combination of slowness of the circulation with a vari. ,post-mortem examination why she should not have recovered. cose condition of the veins plus an extra amount of fibrin The fact that obturator herniæ usually occur in elderly in the blood. May we not) have exactly such a state of persons, especially females, together with the difficulties in things during influenza ? diagnosis, even when the case is not complicated, and the Lavenham, Suffolk. ’frequent delay in operating that consequently ensues, no doub) accounts for the very high mortality that has SOME CASES OF ABNORMAL SWEATING. ,hitherto prevailed in such cases. BY L. FRAZER-NASH, L.R.C.P. & S. ED. Nottingham.

They

were:

sudden and great increase in size of

irreducible hernia in the left groin, followed at

a

once

______________

CASE

1.-Amongst the patients who were attending the Hyderabad Dispensary in 1888 was a Hindu boy, upon whose skin was a crystalline deposit, more or less generally MEDICAL, SURGICAL, OBSTETRICAL, AND distributed, which suggested the idea that the boy had bathed in a saturated solution of some salt that had been THERAPEUTICAL. allowed to dry on him. The crystals were glistening and amorphous to the naked eye, and required some friction to CHOREA FOLLOWING INFLUENZA IN A WOMAN be removed dry. The family history was unimportant. The boy, who was ten years old, had suffered more AGED SIXTY-FIVE. or less since babyhood from malaria, and for four or BY P. A. MCCARTHY, M.D., M.CH., M.A.O. (R.U.I.), &c. five years his mother had noticed these white sweats, which, she said, occurred while he slept. I never ON Jan. 26bh I was called in to see Mrs. A. C-, aged found his skin other than dry, although he attended the dispensary for debility during some of the hottest sixty-five. She had been feeling unwell for some time months. The efflorescence was most marked on the legs, previously, but had taken to bed only the day before. The and notably over the shins; the crystals were also largely usual symptoms of influenza were present, together with a on the back. About the head the crystals were deposited slight cough. Temperature 101° F. In a few days the coarser than elsewhere. The boy was thin, with flabby cough had gone and the temperature fallen to normal, but muscles, and his back was covered with rather.long downy the prostration was very great and anorexia almost com- hair. The heart and lungs were apparently healthy. The plete. Iti was with difficulty she could be persuaded to urine, which I examined on one occasion only when the take nourishment of any kind ; she " felt that she did not efflorescence was fully marked, was acid, sp. gr. 1008; no want it," and " everything had the same salty taste." She change on boiling. The microscope showed the usual complained also of nausea and a burning pain in the pit of phosphates. I tried to examine the skin deposit under the the stomach, and suffered a good deal from flatulence. To microscope, but failed to get more than epithelial scales relieve these symptoms pepsine was given, effclrvescing and amorphous crystals. I regret to say I did not test the draughts, ice, and mixtures containing soda, bismuth, latter chemically, and, owing to press of work, was not able hydrocyanic acid, &c., followed by quinine, strychnine, to take notes as fully as I could have wished. After a

Clinical Notes: