KASHMIR MISSION HOSPITAL.

1127 further strain.

It

was thought also to be reducible. When clearly not reducible into the abdomen, although the lower part of the swelling could be pushed within the inguinal canal ; and its relation to the cord clearly indicated that it was not a hernia. The second

I

saw

it, it

KASHMIR MISSION HOSPITAL.

was

EXCISION OF

GUMMATA OF THE

RECOVERY.—

OPERATION ; RECOVERY. the care of Mr. ARTHUR

which I would comment is the fact that removal of the tumour left a widely distended

clinical feature

TESTICLE ;

STRANGULATED HERNIA; INJURY TO THE BOWEL ;

on

NEVE.) (Under although no special means of closing it GUMMATA of the testis are generally so amenable to were taken there was apparently no tendency to the formation treatment that we seldom see such on the operating of a hernia. This is probably due to two factors at least- ordinary It is profor table the purpose of exploratory incision. the and the of fact the of the preservation canal, obliquity that the cyst had not impaired the integrity of any of the! bable that the conditions under which medical treatment structures bounding the canal-they were stretched, not torn at the Kashmir Hospital is carried out are such as to make or displaced--and when the stretching force was removed it impossible to put the patient under a course of treatthey quickly contracted to their normal proportions with ment sufficiently extended to enable the surgeon to draw conunimpaired strength. clusions. The result of removal was to considerably shorten the after-treatment, which would have been usually resorted to when the diagnosis was confirmed at the operation, and SOUTH DEVON AND EAST CORNWALL it is interesting to observe how easily the gummata were HOSPITAL, PLYMOUTH. removed. It is apparent from the record of the second case EXTENSIVE BURN; HÆMATEMESIS; DEATH; NECROPSY. that considerable violence had been inflicted in the attempts (Under the care of Mr. SWAIN.) to reduce the hernia, which affords another illustration of HÆMORRHAGE from the gastro-intestinal tract does not the statement that no two hernias are alike. The sac gave appear to be a common cause of death after burns. Of sixty- evidence of this by its inflamed state, and the intestine must eight fatal cases collected by Mr. Erichsen only two died as the have been severely bruised. There can be little doubt of result of haemorrhage from duodenal ulcers, and cases such as the importance of the part played by the drainage tube in the following must be rare. It is of course acknowledged, and averting a fatal result. bas been frequently proved, that although many patients CASE 1 -A Kashmiri thirty-five years of age was admitted suffering from burns have definite ulceration in the duodenum, to hospital suffering from a gumma of the right testicle of there are no symptoms on which we can rely to prove their six months’ duration. The organ was of the size of an orange. On Aug. 14th, under chloroform, an incision was made into presence during life, unless they cause haemorrhage or perforate the organ to confirm the diagnosis, with a view to removal the bowel. Hæmorrhagic lesions of the mucous membrane of if necessary. Hydrocele fluid escaped, and a gumma of the the intestine and perforating duodenal ulcers have been fre- size of a pigeon’s egg appeared. The whole testicle was laid quently observed by Rokitansky. Duodenal ulceration may open by a free incision, and the gumma was easily dissected out. By palpation another smaller one was discovered and prove fatal at any time from the fourth to the sixtieth day. The testicle, which had been drawn entirely removed. For this report we are indebted to Mr. R. Stanley Thomas, Iodoform outside the scrotal incision, was now replaced. house surgeon. was dusted into the wound, which was closed by suturing A young woman aged nineteen, when lighting the kitchen with catgut the edge of the testicle to the edge of the fire on Aug. 31st last, caught her dress in the flame and was scrotum all round, so as to prevent hæmatocele, and then severely burnt. She was treated at home for five days, being closing the scrotal wound with the same continuous catgut admitted into the hospital on Sept. 5th. There were extensive suture. The zinco-cyanide gauze dressings were strapped burns of the back, buttocks, and backs of the thighs and legs, firmly on. ranging from the second to the fourth degree. The wounds Aug. 21st.-There has been absolutely no pain. The were very sloughy. The temperature was 103 6° F. ; the pulse wound was dressed six times ; at first a little reddish was 160. The wounds were dressed with zinc and eucalyptus gelatinous discharge was found. On Aug. 31st the patient was dismissed cured. ointment ; she was given milk, brandy, and opium, and was bathed every day for an hour in a very weak disinfectant CASE 2.-A patient fifty years of age came under treatment fluid. On Sept. 14th the baths were stopped, as they exhausted for a strangulated hernia of three days’ standing. Forcible her a great deal and because the sloughs had nearly all attempts at reduction had been made by himself and others. separated. On the 15th the temperature fell to 100°. She He had suffered from constipation and vomiting. The abdoseemed much better and the wounds were becoming very men was tense. The hernia was of the size of a duck’s egg, clean. On the 16th, at 11 A.M , she vomited after food and being hard and tender. On Aug. 15th, under chloroform, the complained of slight pain in the epigastrium ; at 3 P.lvf. she mass was incised. The parts were matted together and was vomiting constantly. The vomited matter had a coffee- oedematous. A very thick sac was found, with blebs of ground appearance characteristic of the presence of blood in serous fluid, but no bowel. On exploring towards the abdoit. She was fed by nutrient enemata and given ice to suck. men some reddish-brown fluid escaped, indicating an injury On the 17th she was vomiting constantly and was very to the bowel. The inflamed sac was excised ; a large drainagecollapsed, but was quite conscious until 3 45 A.M., when tube was passed into the abdominal cavity and the rest of

inguinal canal,

and

’

,

death occurred. The necropsy was made thirty-six hours after death. Postmortem rigidity was marked. On opening the peritoneal cavity the intestines were found to be distended. There was no fluid in the peritoneal cavity and no peritonitis. The small intestines were examined, but no ulceration or congestion of the duodenum was found. The stomach was distended and contained coffee-ground looking material. At the cardiac end there was extensive surgical emphysema. No ulceration was perceptible to the naked eye. Several vessels were much congested. The rest of the mucous membrane was healthy and the peritoneal surface was smooth. Remarks by Mr. THOMAS. -The sudden hæmatemesis, followed by severe and fatal collapse, points to haemorrhage from the stomach. It is probable that some minute ulceration must have taken place in the mucous coat, which produced the fatal haemorrhage, and that the retching caused the emphysema, which was limited to the cardiac end of the stomach. There was no sign of emphysema elsewhere, and decomposition was certainly slow considering the season of the year.

the wound was sutured. He was removed to his home. Two ounces of castor-oil were ordered to be administeied. After midnight the pain was relieved; there was no more sickness, and the bowels acted. On Aug. 19th he began to take liquid food better ; there were a few drachms of offensive dis-

charge.

little discharge ; he takes solid food. A week later he walked into the consulting-room quite briskly, and was allowed to go to his village, taking a little ointment for the almost dry sinus. Remarks by Mr. NEVE.-As regards the first case there appears to be room for more conservative surgery in relation to the testicles, which are often removed for simple neoplasms. Perhaps similar operations to that above recorded may be This is the first operation of the familiar to some surgeons. kind I have performed, and it would be interesting if those who have practised such an operation would record their experiences. In the second case the tumour felt like a strangulated omental hernia owing to the lumpy thickening of the sac. The prognosis seemed to be bad. Probably the

Aug. 25th.-There is

drainage averted

a

fatal

peritonitis.