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ON A CASE OF

STRANGULATED OBLIQUE INGUINALHERNIA TREATED BY INVERTING

THE PATIENT.

BY HENRY POWER, M.B.Lond., F.R.C.S.

ON the 14th ult. William W- presented himself amongstthe out-patients of the Westminster Hospital. He stated thathe was forty-four years of age, a soda-water maker by trade,and that he had suffered from hernia for twenty years. He had

always worn a truss, and though the bowel occasionally slippeddown, he had always been able to replace it by himself. Onthe day previous to his coming, at five o’clock P.M., he waspulling down the sash of a window, when the hernia descendedwith much force in spite of the truss. He immediately wenthome and attempted to reduce it, but his efforts were fruitless;he therefore readjusted the truss and went to bed. He en-dured much pain through the night, and got no sleep. In the

morning he felt sick and vomited his breakfast.On examination a very tense tumour was found in the right

inguinal region. It was about equal in size to a guinea-fowl’s<"egg, and was extremely tender to the touch. I could notascertain whether the hernia was direct or oblique. He com.plained of nausea, and of pain radiating over the whole abdo-men.

I placed him on his back, with the knees drawn up, and for’five minutes endeavoured to reduce the hernia by steady pres-sure, but rao impression whatever was made upon it. Recol-

lecting the plan which was rediscovered or reintroduced by myfriend Mr. Jessop, of Cheltenham, and of which several suc-cessful instances are on record, I obtained the assistance of onefor two of the students and placed the patient on his head.’On again gently compressing the tumour, I had the satisfactionvof feeling it quickly recede, and in less than a minute it entirely- returned, with an audible gurgle.

Grosvenor-terrace, 33elgrave-road, March, 1861.

ON A CASE OF

RUPTURE OF THE SPLEEN.

BY NEVILL JACKSON, M.D., Sumbulpoor;CIVIL MEDICAL OFFICER.

THE following case of rupture of the spleen from slight vio-lence derives additional interest from the evidence it affords of

recovery from a previous injury of the same nature.In November last I was desired to examine the body of a

middle-aged woman who had been found dead, and againstwhose husband suspicions were entertained, as he had dis-

appeared, and had not been seen since the occurrence.The head and chest were examined without result, but the

abdomen was found to contain a large quantity of blood in a,fluid state, derived from an extensive rupture of the spleen.In conducting the previous steps of the autopsy I had noticeda small circular patch of ecchymosis which exactly corre-

sponded with the rupture, and I had therefore no hesitation ingiving it as my opinion that the lesion was probably caused by’a thrust in the side with a stick or other blunt-pointedweapon, and that a very slight degree of violence would sufficeto cause the injury, as the organ was abnormally enlarged and. softened.

n

If the subsequent statement of the husband, made in igno-rance of my expressed opinion, may be taken as confirmatory,this surmise would appear to have been correct, as he confessedto having pushed her in the side with a small bit of cane.

The scar of a previous rupture, about three inches in length,was observed, which had healed in a peculiar manner, theedges being inverted, and presenting rounded, smooth surfaceswhich were not in contact, bands of fibrinous structure appa-rently forming the chief bond of union.

January, 186l.

ST. BARTErOLONIEw’s EospiTAL-&mdash;Dr. Harris has been-elected Assistant-Physician. The Demonstratorship of Morbid.Anatomy is vacant.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

Nulla est alia pro certo noscendi via, nisi quam plurimas et morborum etdissectionum historiM, tam aliomm proprias, collect as habere et inter se com-parare.-MOBGAGNI. De Sed. et Cau8. Aforb., lib. 14. Proaemium.

UNIVERSITY COLLEGE HOSPITAL.

ENCEPHALOID CANCEROUS TUMOUR, OF THE SIZE OF ANADULT’S HEAD, DEVELOPED WITHIN THE SHEATH OFTHE SARTORIUS MUSCLE, SUCCESSFULLY REMOVED.

(Under the care of Mr. ERICHSEN.)

IT is a fact well known to pathologists, that scarcely anypart of the body is exempt from the invasion of cancer. Ofthe three recognised forms of this disease, the encephaloid, ormedullary, especially attacks the different organs, and fre-

quently appears in other places in the form of distinct tumours,first commencing, perhaps, to grow in the site of some smalllymphatic gland. Occasionally a slight injury to a muscle hasgiven rise to this form of cancer, and reports of such instanceshave now and then appeared in our " Mirror." The rup-ture of some of the fibres of a muscle within its sheath willlikewise produce it, if the constitutional predisposition isfavourable for its development. A very remarkable and strik.ing example is at the present time under treatment at Univer-sity College Hospital, of which the following is a brief account.Thomas C-, aged thirty-eight, french-polisher, was ad-

mitted on the 6th instant, with a large tumour situated in thethigh. It appears that ten years ago he suddenly felt some-thing give way in his left thigh, which particularly attractedhis attention, but it was not immediately followed by any symp-tom of consequence. Two years since, however, a small tumourbegan to form at the spot where this sensation was experiencedeight years before-a circumstance which had been well re-tained in his memory. The tumour began to increase in size, andhas grown very rapidly within the last few months, so that nowit is as large as an adult’s head. It commences at the apex ofScarpa’s triangle, extends upwards to the groin, and fills thespace between the rectus femoris and adductor muscles of thethigh. The skin covering it is pale and loose; it has severallarge veins coursing over it; and in general characters thetumour is soft and elastic, and strongly simulates encephaloidcancer. Although the patient is pale, there is an absence ofconstitutional cachexia, and there is no secondary enlargementof lymphatic glands or viscera anywhere to be noticed. Mr.Erichsen therefore determined to remove the mass; and be-fore doing so he stated that the femoral artery could be traceddown to the tumour, and that pulsation was good in the popli-teal and anterior and posterior tibial arteries. There was nocedema of the foot. Neither the femoral vein nor the artery,therefore, was pressed upon. The growth, he said, was notadherent to the bone, but movable in the muscles, althoughindependent of the latter. The tumour had commenced toulcerate at one point, and discharged an offensive serous mat-ter, and there could be no doubt that it would destroy life ifleft. He could not say what the precise state of the partsmight be, but he should be guided by circumstances duringthe performance of the operation.March 13th.-The patient was placed fully under the in-

fluence of chloroform by Mr. Clover, who employed his appa-ratus, by means of which a large air-tight silk bag is filled withair diluted with a certain per-centage of chloroform. By thismethod, not the slightest risk of accident exists, and narcotismis readily produced, by inhaling the air thus mixed withchloroform, in from three to five minutes. We have heardDr. Jenner remark that this is the fairest and most reason-able mode of administering chloroform, because the operatorknows exactly the quantity of this agent which his patientinhales.

, Mr. Erichsen now made a large elliptical incision, including

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a flap of skin adherent to the surface of the tumour, and com-prising the ulcerated part. The integuments were then re-flected off its outer side, and it was found that the growth wasnot adherent to any of the deeper structures of the thigh, andcould be readily detached by the hand to a very considerableextent. It was next freed on the inner side, and its entireunder surface was laid bare. It was firmly held at its upperpart, and, after a little careful dissection, it was detached atthat part by cutting through the whole circumference of thesartorius muscle. In fact, it was this muscle alone that wasinvolved, within the sheath of which the tumour grew, in thesite of the spontaneous laceration of some of its fibres occurringten years before. The large wound remaining resembled aclean dissection of the superficial parts of the thigh. Therectus and adductor magnus muscles were perfectly bare;the femoral vessels were exposed for several inches of theircourse, and the pulsation of the femoral artery could beseen from a distance with the naked eye. Not a vessel of

any importance was wounded, and the operation might havebeen pronounced bloodless were it not for a little welling up ofvenous blood from the lower part of the wound. The wound

appeared to be large from the retraction of the skin, but itsedges were readily brought together by several points ofsuture; the thigh was properly dressed, and the patient re-moved to bed.

In some remarks made afterwards, Mr. Erichsen observed thatthe proper course had been pursued in this instance-viz., theremoval of the tumour. The femoral artery and vein were notimplicated, although exposed for seven or eight inches, and thishe said was a matter of great importance to make out in the firstinstance. The tumour was encephaloid in character; but whathe considered interesting was its development in the sheath ofthe sartorius muscle; this muscle coursed under the base of thetumour, and the latter grew from its anterior part. This wasnot the first time he had met with tumours of a similar charac-ter in this situation. He stated that some years ago he removed,from a boy sent up to him from Lancashire, a cystic tumourwhich was developed in the sheath of the adductor magnusmuscle, and no doubt sprang from its fibres. It was quitepossible, he thought, for a tumour to become developed after astrain or muscular injury. When once the capsule of thetumour is reached with the knife we can proceed to its re-

moval with facility, as occurred in the present instance; andthere was no doubt in his mind that the growth originated inlaceration of some of the fibres of the sartorius ten years ago.

Since the operation the patient has been doing very well; alarge portion of the wound has united by first intention, andit is hopefully anticipated that he will make a good recovery.

GUY’S HOSPITAL.

MALIGNANT TUMOUR OF THE UPPER PART OF THE TIBIA,SUPPOSED TO BE MEDULLARY CANCER ; AMPUTATION

THROUGH THE THIGH.

(Under the care of Mr. COCK.)MR. STANLEY mentions, in his work on " Diseases of the

Bones," that there is a remarkable predisposition in the headof the tibia to take on diseased action-more so, indeed, thanany other bone in the skeleton. Why this should be so hedoes not explain. The exposed position of the tibia, and itsgreater risk of injury, may perhaps have something to do withits extreme liability to become diseased. All the specialmaladies of bone have been known to appear in the head ofthe tibia. A very interesting example of malignant disease inthis situation was admitted lately into Guy’s Hospital.

The patient was a delicate -looking girl, seventeen years ofage, who had had enlargement of the upper part of her rightleg for a year. Latterly she had lost flesh; the swelling of theleg increased, so that it presented a series of irregular pro-minences surrounding the head of the tibia, but evidently pro-ceeding from, and directly involving, the head of that bone.The affected part of the leg was covered with distended veins,and since the rapidity of growth had commenced there wasvery severe and continued pain. Mr. Cock thought there wasno doubt of the malignant nature of the affection, and the onlycourse to be adopted was amputation above the joint.March 12th.-The patient was placed under the influence of

chloroform, and the leg was removed by Mr. Cock, who ampu-tated by means of antero-posterior flaps through the lowerthird of the thigh. All the tissues were flabby, and seemed as

if undergoing fatty degeneration. Very little blood was lost,and the edges of the flaps were brought together by sutures,the limb being bandaged with plaster from the upper part ofthe thigh downwards, thus affording a means of support.The patient is doing as well as can be expected, and the

stump is healing kindly. The nature of the disease proves to,be malignant, as was anticipated. The osseous structure is in-

corporated in the structure of the growth, and is associatedwith the presence of cysts.

ST. BARTHOLOMEW’S HOSPITAL.

CHANCRE OF THE LIP OF A GIRL, WITH SUBLINGUALBUBO.

(Under the care of Mr. COOTE.)

SOME months ago we briefly noticed a case in the West-minster Hospital, under Mr. Holthouse’s care, of syphiliticchancre on the finger, which was followed by buboes on thearm and in the axilla, associated with a well-marked papulareruption. The case was one of interest both from its rarity andfrom the satisfactory diagnosis of its true nature, although the-patient’s history was unsatisfactory. (See THE LANCET, vol. i.,1860, p. 573.)

’ At the present time there is a not less interesting case of anunmarried female, twenty-three years of age, in Treasurer’sward, who was admitted on the 7th inst., with a large chancreon the upper lip, occupying two-thirds of its extent. It is sur-rounded by a hard base, is excavated, and has the appearanceof a true syphilitic ulcer. Conjointly with the chancre-atleast so the patient states-there appeared a swelling beneaththe lower jaw on the right side, which is now (March 16th)soft and fluctuating, and no doubt contains pus. There is alsoa slight swelling on the left side, but not to the same extent.Both of these are undoubtedly syphilitic buboes, although no-history of contamination can be obtained from either thepatient or her mother. No eruption has as yet appeared;nevertheless, all the surgeons who have examined this patientunhesitatingly declare their belief that the ulcer is syphilitic.She is undergoing the usual mode of treatment for this disease,and is improving under the internal use of mercury, togetherwith the local application of poultices and black-wash.We have seen many instances of hospital patients affiicted

with chancres about the lips and on the tongue, and occa-sionally associated with some one of the forms of syphilitic-eruption. Sublingual buboes are more rarely to be witnessed.In the present instance they have been caused by the chancrein the upper lip. According to some pathologists, when a buboforms no secondary eruption will appear. The time has beentoo short for the verification of this doctrine in this patient.

GREAT NORTHERN HOSPITAL.

THE ADVANTAGES OF THE USE OF THE LONG SIDE-SPLINT

IN THE TREATMENT OF MORBUS COX&AElig; IN SOME OF

ITS EARLIER AND MORE CHRONIC FORMS.

FoR some time past, Mr. Price has been treating certaincases of disease of the hip-joint, when not attended with anyexcessive inflammatory symptoms, but accompanied with con-siderable pain and deformity, owing oftentimes to effusion intothe capsule of the joint and rotation inwards of the thigh, bymeans of the long side-splint. This possesses, in his opinion,two main advantages-tkat of keeping the joint at perfect rest,and retaining the thigh-bone and its muscular coverings in sucha position as materially disposes towards subsidence of the swel-ling of the joint, and relief of that kind of pain which is soconstant and distressing when motion is allowed between thevarious structures composing the articulation. The extremestate of flexion and adduction which oftentimes exists in casesof disease of the hips, even in its incipient state, is no bar tothe application of the splint. When manipulation is attendedwith much pain to the little patient, the limb can be broughtinto a straight position with the wing of the pelvis underchloroform. The retention of the parts forming the articula-tion in a state of more or less subacute or chronic inflammationin a new and perhaps constrained position is not, as manymight imagine, attended with increase of the inflammatory