B. Morph. acet. gr.j.; sacchari, gr. x.; 6tis horis sumenda, cum sp. vin. gallic. 3j.; et conf. aromat. gr. x. A starch enema to be administered.

17th. There is still tenderness over the whole belly, which is also tympanitic; she lies, however, on her left side, and the knees are not drawn up; pulse very weak; bowels not open; tongue dry and furred.

18th. The ligature from the omentum came away to-day; the interior of the sac, which has throughout secreted a very unhealthy discharge, is in a sloughy condition, but the destruction does not involve any part of the edges of the skin; the abdomen is now flaccid and free from tenderness; pulse 26, and of much better power. Mr. Erichsen ordered a lotion of the chlorinate of soda to be freely applied to the interior of the sac, and over the whole a bread poultice. The powders were suspended yesterday.

19th. Much better; the sloughs are separating, and the wound is granulating healthily. Pulse 112, soft, and of fair power. From this date, progressive improvement took place, and she was discharged quite well on February 28th.

[The notes of both this and the following case are by Mr. Griffith. The Second Case was one of strangulated congenital hernia, in which a large mass of omentum was also removed, though it was adherent to the testis. This case was likewise under the care of Mr. Erichsen.

From a child

The patient, a man aged 35, was admitted January 7th, at 9 P.M. he has had occasionally a large protrusion, but it had always been readily reduced. He had worn a truss, but it was inefficient. From the 5th of January, however, the tumour had not been reduced, and he had suffered from violent vomiting and constipation. The size of the tumour was that of two fists, long and ovid in form, in the left side of the scrotum. The taxis and chloroform having failed, the operation was proceeded with.]

Having exposed the sac, and divided the stricture, he attempted to effect reduction without opening the former, but, in doing so, it gave way under his hands at the lower part, where it was excessively thin, and a large mass of thickened omentum protruded. The omentum was found to be closely adherent to the testicle. Just within the neck of the sac, and almost concealed by the rest of the tumour, was a knuckle of deeply-congested intestine, of a chocolate-brown colour, but glistening, and otherwise healthy. The stricture was now further divided in the usual direction, and the coil of bowel carefully replaced and retained in position by pressure with the hand over the internal ring. Mr. Erichsen next applied a ligature of whipcord to the neck of the omental protrusion; and, having divided its adhesions to the testis, it was then cut away and removed. This omentum was not only indurated and thickened, but a good deal congested. Mr. Erichsen alleged as his reason for removing it, that if left, it would, from its size, and from the probability that some of it had been a very long time there, almost certainly slough. The wound having been dressed as in the preceding case, the patient was returned to bed, and had administered two grains of opium in the form of pill.

On the morning of the 8th, there was much tenderness over the whole abdomen, and the exposed testicle was acutely inflamed.

Hirnd. xviii. B. Opii gr. ss.; calomel gr. ii.; 4tis horis sumend. Fomentations to the whole abdomen.

On the 9th, he was somewhat better; and by the aid of a simple enema, the bowels were freely opened.

10th. He was so much improved, that the pills were discontinued.

11th. Abdomen distended, but not very tender; the testicle is still swollen and painful; appetite good; bowels open; tongue moist.

18th. The sac has throughout been in a very unhealthy condition, and the whole scrotum is now much swollen and discoloured. As the pus, which is of a dirty grumous character, appeared to lodge in the lower parts, Mr. Gamgee, the homesurgeon, made an extension of the wound lower down, in order to permit of its more free escape.

20th. The patient, as regards his general health, is doing well; the scrotum is injected with red wash. Mr. Erichsen made a counter-opening in its lower portion, in order yet further to obviate the tendency of the pus to bag.

21st. During the night there was a sharp hemorrhage fram the edges of the cut made yesterday, which, however, ceased spontaneously.

Feb. 8th. Steady improvement; all the slough bas separated, and the wound is granulating healthily.

About a fortnight later, the man was discharged quite well.-Med. Times and Gazelle, April 30, 1853, p. 446.

87.-Reduction of a Scrotal Hernia which had been for nearly six months irreduci ble.-Under the care of JOHN HILTON, Esq., at Guy's Hospital.-[Although this hernia had existed in an aggravated form for above six months, and all attempts to reduce it had failed, yet, with the exception of a dragging sensation in the abdomen and back, no symptoms of strangulation had at any time manifested themselves.]

No

On examination, there was found in the left scrotum a large, movable, irregularly nodulated mass (omentum), which was soft, flaccid, and free from tenderness. thing like intestine could be felt. The neck of the tumour at the external abdomi nal ring appeared to be tightly constricted. The bowels were ascertained to have acted regularly each day. Having made careful and persevering, but ineffectual attempts to effect the reduction of the tumour, Mr. Hilton directed-1st, That the man should observe an undeviatingly recumbent posture. 2ndly, That he should have solid food, with not more than half a pint of fluid in twenty-four hours. 3rdly, That a bladder of ice should be kept constantly applied to the scrotum, the latter being elevated on a cushion placed between the thighs. 4thly, That a draught, containing sulphate of magnesia and colchicum wine, should be administered three times daily. Mr. Hilton remarked to those present, that to a young man who had earned his livelihood by hard labour, it was a matter of very great importance to be relieved, if possible, of such an affection as the present, which, apart from the inconvenience necessarily attendant on its bulk, would perpetuate a liability to the occurrence of strangu lation. He pointed out that the important obstacle to reduction was probably offered by the loaded condition of the blood vessels of the protruded part, and that, consequently, the indications for treatment were-1st, to decrease the quantity of the circulating medium generally, as far as might be done without unduly depressing the vital powers; and 2ndly, by local means to constringe and unload the congested vessels of the incarcerated omentum. The one was to be accomplished by purgation, diuresia, and abstinence from fluids; the other, by the recumbent posture and the application of pressure and of cold. With respect to the last mentioned agent, Mr. Hilton further remarked, that, in the case of tumours within the scrotum, the use of cold, by exciting constant and powerful contraction of the dartos, insured the application of the best and most uniform kind of pressure which could possibly be exerted. The effect of purgation was also extremely valuable, since not only did it unload the vascular system generally, but that part of it especially involved in the existing lesion, the omental veins being, with those of the intestines, tributary to the vena porta. It was just possible also, that, by keeping the stomach and transverse colon comparatively empty, the contractions of those organs, to both of which the omentum is attached, might exert some little influence in tending to drag upwards into the abdominal cavity the displaced portion of omentum. To return to our case. After the afore-mentioned treatment had been rigidly pursued for a few days, it was noticed that the man's belly had lost its rounded contour, and become pinched in and narrow; the tumour, also, had diminished in size, and felt soft and loose, having lost its plump and definite form. The bowels had been freely purged.

On the 28th, Mr. Hilton again examined the tumour, and, with very slight pressure, succeeded in passing it up to the abdomen.

On the 30th, the man was discharged, quite free from all the inconveniences of his complaint; aud, by wearing an efficient truss, the hernia had not again protruded.Medical Times and Gazette, May 28, 1853, p. 554.

88.-Operation for Hernia by the Small Subcutaneous Incision. Under the care of J. HILTON, Esq.-[No doubt the much less mortality in hernial cases is owing to a great extent to the present improved method of operating in them. The following, at Guy's Hospital, is a good example. The patient, a female, aged 69, had suffered from severe symptoms of strangulated femoral hernia for thirty-six hours. Being a thin, lax-fibred woman, the relations of the swelling were easily felt.]

Having failed in his attempts at reduction by the taxis, Mr. Hilton at once pro

ceeded with the operation for the division of the constriction. The tumour being held to the outer side by Mr. Maunder, one of Mr. Hilton's dressers, an incision about an inch long was made through the skin and cellular tissue, on the inner side and somewhat below the neck of the sac; a director was next introduced, and by a little care insinuated within the constriction external to the sac. With a small, blunt pointed bistoury the stricture was then notched, after which the bowel returned readily into the abdomen. With the exception of a small portion, not so large as the tip of a finger, the sac had not been seen by the operator. The edges of the wound were at once brought together, and covered by a strip of plaster. All urgent symptoms were at once relieved, and the patient slept fairly during the following night. On the third day, the bowels acted spontaneously, and the plaster having accidentally got rubbed off the wound, the latter was found to have healed completely by the first intention, the cicatrix being, indeed, scarcely perceptible. The woman might be considered as quite well.—Med. Times and Gazette, July 30, 1853, p. 110.

89.-ON WOUNDS OF THE INTESTINES.

By G. J. GUTHRIE, ESQ., F.R.S.

When an incised wound in the intestine is not supposed to exceed a third of an inch in length, no interference should take place; for the nature and extent of the injury cannot always be ascertained without the committal of a greater mischief than the injury itself. When the wound in the external parts has been made by an instrument not larger than one third, or from that to half an inch in width, no attempt to probe or to meddle with the wound, for the purpose of examining the intestine, should be permitted. When the external wound has been made by a somewhat broader and longer instrument, it does not necessarily follow that the intestine should be wounded to an equal extent; unless it protrude, or the contents of the bowel be discharged through the wound, the surgeon will not be warranted in enlarging the wound, in the first instance, to see what mischief has been done. It may be argued that a wound four inches long has been proved to be oftentimes as little dangerous as a wound one inch in length; yet most people would prefer having the smaller wound, unless it could be believed that the intestine was injured to a considerable extent. Few surgeons even then would like to enlarge the wound, to ascertain the fact, unless some considerable bleeding, or a discharge of fæcal matter, pointed out the necessity for such an operation.

If the first two or three hours have passed away, and the pain, and firm but not tympanitic swelling in the belly, as well as the discharge from the wound, indicate the commencement of effusion from the bowel, or an extravasation of blood, an enlargement of the opening alone can save the life of the patient. The external wound should be enlarged, the effused matter sponged up with a soft moist sponge, and the bowel or artery secured by suture. When a penetrating wound, which may have injured the intestine, has been closed by suture, and does not do well, increasing symptoms of the inflammation of the abdominal cavity being accompanied by general tenderness of that part, with a decided swelling underneath the wound, indicating effusion beneath, the best chance for life will be given by re-opening the wound. It is a point in surgery, which a surgeon should contemplate in all its bearings. The proceeding is simple, little dangerous, and under such circumstances can do no harm. When the wounded bowel protrudes, or the external opening is sufficiently large to enable the surgeon to see or feel the injury by the introduction of his finger, there should be no difficulty as to the mode of proceeding. A puncture or cut, which is filled up by the mucous coat, so as to be apparently impervious to air, does not demand a ligature.

An opening which does not appear to be so well filled up as to prevent air and fluids from passing through it, as such wound cannot usually be less than two lines in length, should be treated by suture. When the opening is small, a tenaculum may be pushed through both the cut edges, and a small silk ligature passed around, below the tenaculum, so as to include the opening in a circle, a mode of proceeding I have adopted with success in wounds of the internal jugular vein, without impairing its continuity; or the opening may be closed by one, two, or

more continuous stitches, made with a very fine needle and silk thread, cut off in both methods close to the bowel, the removal of which from the immediate vicinity of the external wound is little to be apprehended under favourable circumstances. The threads or suture will be carried into the cavity of the bowel, as has been already stated, if the person survive; and the external part of the wounded bowel will either adhere to the abdominal peritoneum, or to one or other of the neighbouring parts. When the intestine is more largely injured, in a longitudinal or transverse direction, or is completely divided as far as, or beyond the mesentery, the continuous suture is absolutely necessary.

When the abdomen is penetrated, and considerable bleeding takes place, it is necessary to look for the wounded vessel. When the hemorrhage comes from one of the mesenteric arteries, or from the epigastric, the wound is to be enlarged until the bleeding artery is exposed, when ligatures are to be placed on its divided ends, if they both bleed. I have seen the epigastric artery tied several times with

success.

A Portuguese caçador on picquet was wounded at the second siege of Badajos, in a sally made by some French cavalry. He had three or four trifling cuts on the head and shoulders, and one across the lower part of the belly on the right side. He bled profusely, and when brought to me had lost a considerable quantity of blood, which came through a small wound made by the point of a sabre. This wound I enlarged until the wounded but undivided artery became visible; upon this two ligatures were placed, and the external wound was sewed up. The peritoneum was opened to a small extent, but the bowel did not protrude, and the patient (not being an Englishman, and not therefore so liable to inflammation) recovered after being sent to Elvas.

A soldier of the same regiment, cut down at the same time, died as he was brought into camp, having been severely wounded in the chest and the abdomen. He was said to have died from hemorrharge, from a wound in the belly, two inches in length, made by one of the long-pointed swords of the French dragoons. I had the curiosity to enlarge the wound, and found one of the small intestines had been cut half across, another part injured, and that the blood had come from an artery which had been opened by the point of the sword in going through the mesentery, which wound had caused his death.

The recollection of these and of other nearly similar cases causes me to say that when hemorrhage takes place from within the abdomen the wound should be enlarged; and that if an artery in the mesentery, or in any other place which can be got at, should be found bleeding, a very fine silk ligature should be placed, if possible, on each side of its divided extremities, and cut off close to the knot, the external wound being afterwards accurately closed. This is a point of practice to which future attention is directed.

When a musket-ball penetrates the cavity of the belly, it may pass across in any direction without injuring the intestines or solid viscera. It usually does injure one or the other, and it has been known to lodge without doing much mischief. The symptoms are generally indicated by the parts injured, although in all the general depression and anxiety are remarkable; their continuance marks the extent, if not the nature of the mischief.-Lancet, April 20, 1853, p. 399.

90.-CASE OF INTESTINAL OBSTRUCTION FROM DISEASE OF THE RECTUM.

TREATED SUCCESSFULLY BY OPENING THE DESCENDING COLON IN THE LEFT LOIN. By ALFRED BAKER, Esq., Surgeon to the General Hospital, Birmingham.

[The patient in this case was a tall spare woman, aged 62. Mr. Baker saw her on the 15th August, 1849. She had great pain in the lower half of the body, with severe retching and some vomiting. These symptoms were supposed to arise from her eating some indigestible food. Calomel, purgatives, and enemata were prescribed, by which the symptoms were relieved. On the 1st October, 1849, she had a worse attack of the same kind, and complicated with double femoral hernia. With appropriate treatment she again recovered. On the 9th November, of the same

year, on being again sent for, Mr. Baker found many symptoms of intestinal obstruction present, and on examining the rectum, which he was led to do from the deep-seated pain in the sacrum, and other symptoms, Mr. Baker says:]

I found that, within reach of the tip of the finger, the bowel was obstructed by a firm growth, occupying its whole circumference: this had an uneven surface, and a dense consistence; near its centre was a small fossa, which appeared to be the lower orifice of the contracted portion of the canal. I attempted to dilate this opening with the finger, but its distance from the anus rendered this proceeding useless, and the slightest pressure from below pushed the strictured part upwards. The uterus was quite healthy, and could be moved independently of the diseased bowel. As the stricture did not seem to produce complete occlusion, she was ordered to take two pills every fourth hour, composed of five grains compound extract of colocynth and five grains of extract of conium; and an enema was given with the ordinary syringe, in the hope that some of it would pass through the contracted canal, and thus liquefy the accumulation above. Next day, finding that the enema had been expelled, after a few minutes' retention, without any fæces, and that the symp toms were unabated, I attempted to pass a small oesophagus-tube, and succeeded in penetrating the stricture for a short distance, but could not get through it; some fluid was, however, injected along the tube, all of which did not return. On the following day, finding that a little dark-coloured liquid stool had been voided, the tube was again tried; and a quarter of a drop of croton oil was added to each dose of the pills. By perseverance in this treatment, the bowels were, after two or three days, partially unloaded; and I hoped that time would now be gained for the dilatation of the stricture, with which object bougies of small size were employed, but with only a small amount of success. In a few days constipation returned, accompanied by symptoms of peritoneal inflammation. Her pulse rose to 100, she had loss of appetite, thirst, dry tongue, heat of the skin, with short and hurried breathing. The abdomen, which had been softer and smaller, again became tense, tumid, and tender, and her suffering was increased by very slight pressure upon it. She now took two grains of calomel with the fourth of a grain of opium every four hours; croton oil liniment was rubbed freely over the abdomen, and hot fomentations were assiduously applied. Under these measures she improved; the symptoms of peritonitis disappeared, the size of the abdomen was lessened, and diarrhoea shortly came on. The diarrhoea was not controlled by any stringent, but in a few days spontaneously subsided.

[On the 17th January, the condition of the patient was much aggravated. The return was completely occluded; therefore, he continues:]

At eight o'clock p.m., January 23rd, 1850, in the presence of Dr Heslop, Mr. Hale and Mr. James, I opened the descending colon in the left lumbar region, where it is not enveloped by the peritoneum. The patient being laid upon her face in bed, and her truss removed, lest it should interfere with the operation, an incision was made transversely across the left loin for five inches, commencing about two inches from the spine, and carried outwards midway between the last rib and the crest of the ilium. By this the skin and subcutaneous cellular membrane were divided; after which the latissimus dorsi, quadratus lumborum, and the lumbar fascia, were in succession cut through. The loose fat, which in persons who are not very much emaciated always exists in this situation, projected at the bottom of the wound, and an attempt was made to push it aside, so as to allow the bowel to come forward; this proceeding, however, failed, and it was necessary to remove several large masses of fat by the knife before the colon became visible. At first the intestine did not project, and the finger was passed into the wound to ascertain the cause; the cellular connections of the colon with the loin were thus broken down, and, on the withdrawal of the finger, the intestine distinctly projected at the bottom of the wound, having a pale, leaden, and greenish hue. It was next attached by four sutures to the skin at the edges of the first incision, and was then opened by a scalpel to the extent of an inch between the threads. A rush of most offensive air took place immediately that the bowel was punctured, and a stream of chocolate-coloured fæces, of the consistence of thin gruel, welled up from the opening. This continued to flow until more than a large wash hand basin had been filled, when it ceased The wound was then covered with pledgets of linen dipped in warm water; and a thickly-folded sheet was placed under the patient, and she was turned upon her back