382 Ileus and Strangulated Hernia, treated by Opium.

that the right carotid and innominate has suffered to a considerable extent, and to accommodate such an arrest of the circulation that the aortic arch has undergone dilatation, more especially about the ascending and transverse angle, which secondary aneurismal dilata- tion, so to speak, is pressing on tile right bronchus and nutrient vessels, and has given rise to an atrophic condition of the right lung, with symmetrical flattening and failing in of the right side, and consequent spinal deformity.

" And further, when we take into account the giddiness, loss of consciousness and speech, with the transient attack of paralysis so clearly described by the patient, we must look upon them as symptomatic of a still further extension of the atrophy, in a diminished capacity of the right cerebral hemisphere, the result of obstruction of the right carotid artery and its tributaries. Judging from the symptoms and physical signs in this case, it appears to me to bear a close analogy, in its results, to a case of thoracic aneurism which was under my care some time ago in the hospital, in which "there was loss of speech, memory, and disorders of the intellect, with paralysis of motion and sensation, depending (as verified by pathology) on an atrophic condition of the left half of the brain, the result of an impervious left carotid a~:tery, from an aneurism of the transverse portion of the arch of the aorta. Lastly, this case is full of interest, in a psychological point of view, as showing how a surgical injury, in a comparatively remote region, can secondarily effect the sensorium.

"Believe me to be, yours very truly, " W I L L I A M MOORE.

"R. G. BUTOHER~ :Esq., M.D., &c."

ART. XI.--Cases in Practice of ileus and Strangulated Hernia, treated by Opium--the Case of Ileus also treated b?] Puncture. By J. W. MARTI:N, F.R.C.S.I . , Portlaw.

IN the year 1863 I wrote a short article on ileus, which appeared at the time in the Medical Press. I then sa id : - -" In many cases it is difficult, in most impossible, to form an accurate diagnosis of the cause of obstruction; our treatment must therefore be, in a great measure, empirical. This being the case, we should adopt that course of treatment most likely to prove serviceable in the greatest

By DR. MARTIN. 383

number of cases. This appears to me to be the early and steady administration of opium." I then had twenty years' experience of the advantages to be gained by this plan of treatment, at that time not generally adopted. Twelve years since have confirmed me in my good opinion of its value; indeed, at one time, I had the outlines of a brochure on the subject drawn up, intending to publish it; but, walking into Messrs. Fannin & Co.'s shop in Grafton-street one day, with my mind hot on the subject, I found myself fore- stalled by Brinton's very valuable little posthumous treatise on the subject, which contained all I had to say about it. Since then I had two or three 'cases, in which, having given opium freely for some days, the action of the bowels was induced by the use of enemata, containing several ounces of recent oxgall diluted with warm water.

The following case will be of interest, showing, as it does, that there are other measures which may be adopted with advantage, in addition to the foregoing.

I was sent for to a neighbourlng village to see a man, aged seventy-five years; he had been attacked with colicky pains four days before, for which he had been treated with active aperients and enemata without producing any action of the bowels; the pain had increased; the abdomen had become much swollen and tym- panitlc; his countenance anxious; some vomiting; pulse 120, small, irregular; and he insisted that he was dying.

I introduced the O'Beirne's tube for twenty-elght inches, not only without difficulty, but also satisfying myself that, in this case at all events, it passed the sigmoid flexure; some flatus escaped; I threw in an enema of turpentine and oil mixed in emulsion. On withdrawing the tube an effort was made at expulsion, but without success. I introduced the tube again, and pumped out part of what I had injected, mixed with fmcal matter, but no relief was obtained. I then determined to puncture the distended bowels, and did so with a fine trocar and canula, about two inches below the ribs, on a line with the left nipple; much flatus escaped, but the tube at last became stopped with feculent matter. I then repeated the puncture about two inches more towards the llnea alba with similar results. There was almost immediate relief from the extreme suffering, and one-third of a grain of morphia given subcutaneously procured some hours sleep; the dose was repeated by the mouth at night, and next morning there was free action of the bowels.

384 Ileus and Strangulated Hernia, treated by Opium.

Visiting him six days afterwards I found him comparatively well, but suffering from dlarrh~ea, for which I prescribed an astringent chalk mixture, with laudanum. Yesterday, twelve days after, a neighbour of his told me he was quite well. There was not the slighest suffering or mischief from the puncture. I should say that I took care, by compression, to keep the peritoneal sur- faces in contact while the instrument was penetrating the bowels. This case leads me to make some remarks on the value of opium in cases of incarcerated hernia.

In a paper I wrote on the subject some years ago--I cannot recal to mind in what periodical or at what date--I drew attention to the practical distinction to be made between strangulated and incarcerated hernia. I would now again address myself to the point.

A sharp line of distinction cannot be drawn, but tact, attention, and practice, will enable us soon to settle approximately the symp- toms which should decide us on either proceeding promptly to operation, or adopting other courses with a view to promoting the return of the hernia. I would say that, if the patient be young and healthy, the hernia recent, small, tense, and painful to the touch, with the abdomen hard, and either retracted or distended and tympanitlc, prompt operation is the safest remedy. But in the aged--when the hernia is large and of long standing--whr if a truss has not been worn, the parts have had time to accommodate themselves to the abnormal state, or, when a truss being worn, a large mass suddenly protrudes; when handling gives but little pain or suffer- ing--in such, I think, other remedial measures may have fair trial. The warm bath, if convenient, or, what I prefer, large hot fomen- tations, and a moderate trial of the taxis, preceded by a large dose of opium--I prefer this to either chloroform or tobacco.

In the Medical Press, 1863, I published a case in which I was successful in reducing a badly incarcerated hernia, under the in- fluence of opium, being the third case in which I had used it successfully. The following cases have also occurred in the course of my practice.

J . A., aged fifty-eight, a stone-mason, has had a right inguinal hernia for several years, for which he wears a truss, but, from the nature of his employment, lifting heavy weights, it sometimes pro- trudes. A year ago it became incarcerated, but, after a moderate dose of laudanum, was easily reduced. On this occasion, when

By Dm MARTIN. 385

lifting a heavy stone, the hernia came down, and he could not reduce it. Having been away from home most of the day, I found, on my return in the evening, that my assistant had been sent for three hours before, had tried the taxis, and, finding he could not reduce it, gave 25 drops of Battley's sedative. On visiting him found the hernia about the size of a goose e~*o~,, and the patient suffering great pain. I tried the taxis again, patiently, for nearly an' hour, when I made up my mind that the case would require operation. Not having had dinner, I gave him forty drops more of J3attley, and went to have some refreshment, and prepare the requisites for operating. On returning, after an hour, I again tried pressure, and had not the herni,~ five minutes in my hand when it returned easily, and all went well.

I was called about 3 a.m. to see J. F., aged twenty-five, delicate of frame and constitution. He had a left inguinal hernia, tbr which he habitually wore a truss by day, but left it off at night. On this occasion, during a fit of coughing, the hernia protruded, and, becoming painful, he sent for me. I found him in great agony; his pulse sharp and rapid; countenance anxious; the hernia had been down four hours, and felt tense; he had vomited once. I tried the taxis, got him into a hot bath, and there repeated the attempt to reduce it, but without making the slightest im- pression upon the swelling. I then determined to have recourse to the operation, and wrote to a friend to come and assist me; but as he could not reach me for four hours, I gave two grains of opium, and directed one to be taken every hour, keeping up a hot fomentation with flannels and impervious cloth. When my friend arrived, four grains of opium had been taken. He suggested chloroform; and I was about to leave the house to procure it, when the hernia receded under the slightest pressure of his hand. We applied his truss; his bowels responded to a dose of black draught, and he recovered rapidly.

Two years ago I was called at midnight to visit a small farmer, about four miles from my residence. He was aged seventy-five ; wore a truss for an old inguinal hernia, which had come down on the previous evening, and not being able to reduce it, as he was used to do, it became painful; colicky pains set in, and he felt very ill. Having been apprised of the nature of the case, I brought my son, Dr. John Martin, with me, and the necessary articles for an operation. I found the man suffering greatly; the hernia of very

2 E

386 Surgical Reports and Observations.

large size; solid, as if containing omentum, and tender to the touch. I first threw in one-third of a grain of muriate of morphia under the skin, and tried the taxis, but without success. I then applied the ether spray, which produced great contraction of the skin and loose structures; but two hours passed without making any impression on the hernia. I then threw in half a grain of the morphia subcutaneously, and, waiting for half an hour, again tried the taxis, which was very speedily successful, and the patient made an excellent recovery.

A few years ago I was requested by a confrere to visit a patient in the Poorhouse Hospital under his care, on whom he meditated operating for the relief of an incarcerated hernia, but for which he was strongly advised by a mutual medical friend to try the opium treatment. I found the patient to be a wretched object, vomiting constantly; abdomen tumid, but not tense, and the hernia bore handling well, not being at all tender; still the taxis made no impression on it. Feeling satisfied that it was not strangulated, I, too, voted for the oplmn treatment, and he was ordered a grain every four hours, frequent enemata of warm milk and broth, and hot fomentations to abdomen and hernia. This llne of treatment was continued for eleven or twelve days, when the hernia receded spontaneously; the bowels acted after having had no motion for fourteen days; and the patient recovered so rapidly that he left the house four or five days afterwards quite well.

W h a t became of the eighty or ninety grains of opium he took ? for he showed no sign of narcotlsm all through his illness.

ART. XII.--Surgical Reports and Observations. By A~THOI*u H. CORL•Y, M.D., F .R.C.S.I . ; Surgeon to Jervis-street Hospital; Lecturer on Surgery, Carmlehael School of Medicine.

[Continued from 2" 309.]

IV.--ItARE DISLOCATION OF HIP. V.--ICttTItYOSIS A~D EPITItELIOMA OF TONGUE ; EPITHELIOMA

OF LIP ; OPERATIONS. VI.--I~P~FO~ATE RECTUM; OPERATION; ~ECOVEaY.

IV.-- Rare Dislocation of Hip. MR. O':N., a strong, healthy man, who told me that " h e knew his age was seventy-four, but that it might be more," was standing beside a field-gate on 2nd June, 1874. The gate was overturned by a young