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CASE OF STRANGULATED OBTURATOR HERNIA, COMBINED WITH REDUCIBLE FEMORAL HERNIA;
710 whole; it is the life that selects the nutrition best suited to its individual self ; it is the life that has to do with the continuation of its species; lastly, it is the life to which the molecular lives which make up the structure are subordinated, and when this nameless life departs, these myriad
lives, no longer co-operating, start on an independent course.
SLOUGHING OF THE CORNEA IN CONNEXION WITH DISEASE OF THE FIFTH NERVE. BY
tion, which
commences in the pit of the stomach, and extends to the limbs; and he has at times a, rather severe pain at a spot deep in the neck, between the angle of the jaw and the sterno-mastoid muscle. His tongue is furred; and I observed that he had lost all the molar teeth upon the right side. The man has always had plenty to eat and drink, has never suffered from any constitutional disorder, and is free from cardiac, pulmonary, or any other disease that I can ascertain. The right eye is good, and the fundus normal.
gradually
Newcastle-upon-Tyne, Oct. 1871.
C. S. JEAFFRESON,
CASE OF
ASSISTANT-SURGEON TO THE NEWCASTLE-ON-TYNE INFIRMARY.
THE influence of the fifth nerve upon the nutrition of the eye has been.investigated by many physiologists ; and Magendie, Longet, and others, have shown that destruction of this organ follows its division. It is rare, however, in practice to meet with cases which illustrate the pathological bearing of these experiments; and in few of our text-books on ophthalmic surgery do I find disease of the fifth nervei assigned as a cause of ulceration of the cornea. It is my belief that this neurotic origin of corneal disease is not unfrequently overlooked; and yet, when once the attention is! directed to it, its symptoms are found to be very striking and peculiar. The extent of the disease-the curious, dry, leathery appearance of the sloughing cornea-the purple colour of the ocular tunics-are quite different from what is seen in ordinary inflammatory affections. The absence of secretions-the almost entire absence of pain and the tolerance of light, however intense-are very characteristic; and when to these symptoms are added the complete anaesthesia of the cornea and an absence of sensation in the whole of the conjunctival surface of the globe and lids, a picture is drawn which it is not difficult to recognise. I am afraid it is useless to speculate as to the exact nature and locality of the changes which, in the case I have reported below, gave rise to the lesion of the eye. Many physiologists assert that it is through the medium of the sympathetic that the fifth nerve influences the processes of nutrition; and experimental physiology has shown that removal of the superior cervical ganglion of the sympathetic is followed by the same train of symptoms, as far as the eye is concerned, as division of the fifth nerve. In my case the patient’s chief complaint was of a pain deep in the neck in the region of the ganglion above-mentioned; and its value as a symptom was much enhanced by his having made this statement quite spontaneously. G. B-, aged forty-three, a foreman in a large bootmaking establishment, came to me under the following circumstances :-Three weeks ago, on awakening one morning, he observed the sight of the right eye was dim. Two days after this the ocular tunics became slightly vascular. On the third day a speck made its appearance on the centre of the cornea; and upon the ninth day the whole of the cornea had become quite white. I saw him on the fifteenth day, and found the eye in the following condition :-The conjunctival epithelium and anterior elastic lamina of the cornea had sloughed, with the exception of a small portion round the extreme edge; its fibrous laminsa had become converted into a dead-white leathery substance, which could be stripped off in fine layers. The conjunctiva was of a muddy purplish colour; there was slight chemosis, but a remarkable dryness of its surface and of that of the cornea. The whole of the globe and the inner surface of the lids was completely ancesthetic-so much so that he was unconscious when they were touched, or an irritant solution was brought in contact with them. There was partial anaesthesia of all parts supplied by the cutaneous nerves of the ophthalmic division of the fifth; and the anaesthesia was complete over a small space covering the right malar bone. He has no pain in the eye, but says it feels numb. There is no intolerance of light, and he can just distinguish the position of the window. There are few subjective symptoms. Occasionally he says he is attacked by a kind of trembling sensa-
STRANGULATED OBTURATOR HERNIA, COMBINED WITH REDUCIBLE FEMORAL HERNIA; SLOUGHING OF THE GUT, PERITONITIS, AND DEATH, BY A. J.
NEWMAN, M.R.C.S.ENG., L.R.C.P.EDIN.
THE following case, occurring in the practice of Mr. Matthew Brumell of Morpeth, is one which, from its complications, presents points of sufficient interest to induce When the me to lay it before the readers of THE LANCET. symptoms remained unrelieved after the reduction of the femoral hernia, it became a question as to whether an operation ought not to be performed in case of there being any small strangulated portion of gut remaining in the femoral canal. In consequence of the complete absence of either swelling or tenderness, however, it was resolved notto resort to such a proceeding. The length of time elapsingbetween the advent of urgent symptoms and death is worthy of note. M. S-,aged seventy-three, was seen on the 4th of’ November, 1870, and found to be suffering from a strangulated femoral hernia on the right side, with considerable tenderness over the tumour, and pain in the belly, right thigh, and knee. She had suffered from hernia many years, and had before come under treatment with the sameresults when unable to reduce it herself. She had refused to wear a truss. The hernia was reduced by the taxis, without much difficulty. The symptoms of obstruction did not, however, disappear after this reduction. The pain,. uneasiness, and constipation continued; and on the 7th vomiting of stercoraceous matters in large quantities came These symptoms remained unabated until the patient’son. death, which took place on the 19th of November (the sixteenth day after the accession of the hernial attack). Increase of pain, with more marked tenderness of the belly,. was present for the last fifty or sixty hours preceding dissolution. Autopsy, fifty-.four hours after death. On opening the abdomen, the intestines in the right iliac fossa were seen to be of a darker colour than in the other parts of the cavity, and had some partially organised lymph over their surface and that of the omentum. The abdominal cavity contained a small quantity of thick dark-yellow fluid, evidently feculent in character. The femoral ring was patent, and the finger could with ease be pushed into it. At about sixty inches from the caecum a portion of the ileum was adherent to the abdominal wall, and was found to be drawn into a pouch of peritoneum, which protruded through the upper and inner corner of the right obturator foramen. Here it was firmly retained, requiring some considerable amount of pulling, and at last pressure from the femoral side of the foramen, to dislodge it. Not more than an inch of intestinewas strangulated, and this was found to be of a dark plum colour, perforated at its jejunal end by an opening admitting a small goose-quill. The intestine above the strangulated portion contained air and fluid, whilst below it was flaccid and empty. The point of the little finger could be passed into the hernial sac with difficulty. A corresponding small sacculus of peritoneum was found to exist in theopposite foramen. Windermere, 1871. -
lives, no longer co-operating, start on an independent course.
SLOUGHING OF THE CORNEA IN CONNEXION WITH DISEASE OF THE FIFTH NERVE. BY
tion, which
commences in the pit of the stomach, and extends to the limbs; and he has at times a, rather severe pain at a spot deep in the neck, between the angle of the jaw and the sterno-mastoid muscle. His tongue is furred; and I observed that he had lost all the molar teeth upon the right side. The man has always had plenty to eat and drink, has never suffered from any constitutional disorder, and is free from cardiac, pulmonary, or any other disease that I can ascertain. The right eye is good, and the fundus normal.
gradually
Newcastle-upon-Tyne, Oct. 1871.
C. S. JEAFFRESON,
CASE OF
ASSISTANT-SURGEON TO THE NEWCASTLE-ON-TYNE INFIRMARY.
THE influence of the fifth nerve upon the nutrition of the eye has been.investigated by many physiologists ; and Magendie, Longet, and others, have shown that destruction of this organ follows its division. It is rare, however, in practice to meet with cases which illustrate the pathological bearing of these experiments; and in few of our text-books on ophthalmic surgery do I find disease of the fifth nervei assigned as a cause of ulceration of the cornea. It is my belief that this neurotic origin of corneal disease is not unfrequently overlooked; and yet, when once the attention is! directed to it, its symptoms are found to be very striking and peculiar. The extent of the disease-the curious, dry, leathery appearance of the sloughing cornea-the purple colour of the ocular tunics-are quite different from what is seen in ordinary inflammatory affections. The absence of secretions-the almost entire absence of pain and the tolerance of light, however intense-are very characteristic; and when to these symptoms are added the complete anaesthesia of the cornea and an absence of sensation in the whole of the conjunctival surface of the globe and lids, a picture is drawn which it is not difficult to recognise. I am afraid it is useless to speculate as to the exact nature and locality of the changes which, in the case I have reported below, gave rise to the lesion of the eye. Many physiologists assert that it is through the medium of the sympathetic that the fifth nerve influences the processes of nutrition; and experimental physiology has shown that removal of the superior cervical ganglion of the sympathetic is followed by the same train of symptoms, as far as the eye is concerned, as division of the fifth nerve. In my case the patient’s chief complaint was of a pain deep in the neck in the region of the ganglion above-mentioned; and its value as a symptom was much enhanced by his having made this statement quite spontaneously. G. B-, aged forty-three, a foreman in a large bootmaking establishment, came to me under the following circumstances :-Three weeks ago, on awakening one morning, he observed the sight of the right eye was dim. Two days after this the ocular tunics became slightly vascular. On the third day a speck made its appearance on the centre of the cornea; and upon the ninth day the whole of the cornea had become quite white. I saw him on the fifteenth day, and found the eye in the following condition :-The conjunctival epithelium and anterior elastic lamina of the cornea had sloughed, with the exception of a small portion round the extreme edge; its fibrous laminsa had become converted into a dead-white leathery substance, which could be stripped off in fine layers. The conjunctiva was of a muddy purplish colour; there was slight chemosis, but a remarkable dryness of its surface and of that of the cornea. The whole of the globe and the inner surface of the lids was completely ancesthetic-so much so that he was unconscious when they were touched, or an irritant solution was brought in contact with them. There was partial anaesthesia of all parts supplied by the cutaneous nerves of the ophthalmic division of the fifth; and the anaesthesia was complete over a small space covering the right malar bone. He has no pain in the eye, but says it feels numb. There is no intolerance of light, and he can just distinguish the position of the window. There are few subjective symptoms. Occasionally he says he is attacked by a kind of trembling sensa-
STRANGULATED OBTURATOR HERNIA, COMBINED WITH REDUCIBLE FEMORAL HERNIA; SLOUGHING OF THE GUT, PERITONITIS, AND DEATH, BY A. J.
NEWMAN, M.R.C.S.ENG., L.R.C.P.EDIN.
THE following case, occurring in the practice of Mr. Matthew Brumell of Morpeth, is one which, from its complications, presents points of sufficient interest to induce When the me to lay it before the readers of THE LANCET. symptoms remained unrelieved after the reduction of the femoral hernia, it became a question as to whether an operation ought not to be performed in case of there being any small strangulated portion of gut remaining in the femoral canal. In consequence of the complete absence of either swelling or tenderness, however, it was resolved notto resort to such a proceeding. The length of time elapsingbetween the advent of urgent symptoms and death is worthy of note. M. S-,aged seventy-three, was seen on the 4th of’ November, 1870, and found to be suffering from a strangulated femoral hernia on the right side, with considerable tenderness over the tumour, and pain in the belly, right thigh, and knee. She had suffered from hernia many years, and had before come under treatment with the sameresults when unable to reduce it herself. She had refused to wear a truss. The hernia was reduced by the taxis, without much difficulty. The symptoms of obstruction did not, however, disappear after this reduction. The pain,. uneasiness, and constipation continued; and on the 7th vomiting of stercoraceous matters in large quantities came These symptoms remained unabated until the patient’son. death, which took place on the 19th of November (the sixteenth day after the accession of the hernial attack). Increase of pain, with more marked tenderness of the belly,. was present for the last fifty or sixty hours preceding dissolution. Autopsy, fifty-.four hours after death. On opening the abdomen, the intestines in the right iliac fossa were seen to be of a darker colour than in the other parts of the cavity, and had some partially organised lymph over their surface and that of the omentum. The abdominal cavity contained a small quantity of thick dark-yellow fluid, evidently feculent in character. The femoral ring was patent, and the finger could with ease be pushed into it. At about sixty inches from the caecum a portion of the ileum was adherent to the abdominal wall, and was found to be drawn into a pouch of peritoneum, which protruded through the upper and inner corner of the right obturator foramen. Here it was firmly retained, requiring some considerable amount of pulling, and at last pressure from the femoral side of the foramen, to dislodge it. Not more than an inch of intestinewas strangulated, and this was found to be of a dark plum colour, perforated at its jejunal end by an opening admitting a small goose-quill. The intestine above the strangulated portion contained air and fluid, whilst below it was flaccid and empty. The point of the little finger could be passed into the hernial sac with difficulty. A corresponding small sacculus of peritoneum was found to exist in theopposite foramen. Windermere, 1871. -