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<ul><li><p>960</p><p>used in approximating the pillars of the ring seems doubtful,eurgeons still differing as to the advisability of using wire,catgut, or silk.CASE 1.R. J---, a bricklayer, aged forty-four, was</p><p>admitted on May 10th, 1887. For nine years he had had aright scrotal hernia, which had been strangulated two yearsago, but was reduced by taxis.The right half of the scrotum was as big as a mans fist,</p><p>and very tense; the hernia had been down for fourteenhours, and all the signs of strangulation were present. Taxishaving failed, herniotomy was performed. The sac beingopened, about two feet of congested small intestine wereexposed; the strangulation was divided at the neck of thesac. An atrophied testis was seen at the bottom of the sac.The neck of the sac and the spermatic cord having beenseparately tied with strong catgut, the testis and the sacwere removed together. Four strong wire sutures were </p><p>then deeply passed through the pillars of the external ringand the conjoined tendon, and the inguinal canal was thusobliterated. The wound was washed with a 1 per 1000mercuric solution, a drainage tube was introduced, and theedges of the wound were brought together with wire sutures.The patient was kept on iced water for twenty-four hours,and quarter-grain doses of morphia were administered.There were no febrile symptoms. (The epididymis was sub-sequently examined by the microscope for seminal filaments,but with a negative result.)On the eighth day the wound had healed throughout, the</p><p>sutures were removed, and the dressings were left off. Thetube had been withdrawn at the end of twenty-four hours.Thirteen days after the operation the patient was allowedto get up, there being a large plug of dense tissue filling upthe inguinal canal and surrounding the external ring. Onthe eighteenth day, however, some pus was detected beneaththe scar; this was let out and the dressings were reapplied.On the thirty-fourth day the man was discharged. But at theend of two months he was readmitted, as some suppurationcontinued. The four deep sutures were therefore removed ;two of them were found firmly embedded in fibrous tissue;the two others were loose. The wounds at once healed bygranulation, there being a mass of hard new tissue soundlyfilling the canal and covering the external abdominal ring.The patient was discharged cured, and was directed not towear a truss.CASE 2.--F. L, aged eighteen, was admitted Aug. 16tb,</p><p>1887. His right inguinal hernia had tirst appeared sud-denly, nine years before, whilst he was pushing a truck.He was greatly collapsed, though the bowel had been downand strangulated only three hours ; taxis was unavailing.The details of the herniotomy closely resembled those of thepreceding case. An atrophied testis was found in the sac;the neck of the sac and the cord were ligatured separately,and the testis and the sac were removed. The external ab-dominal ring and the inguinal canal were obliterated bymeans of sutures, which included the conjoined tendon,together with parts of the aponeurosis of the externaloblique, strong chromicised gut being used instead of silver.</p><p>After twenty-four hours the tube was removed. On theseventh day the dressings were left off, as the wound hadhealed completely. On the eighth day the patient wasallowed to sit up. On the fifteenth day he was discharged.There was abundant firm material blocking up the canaland surrounding the external ring, but it was not soplentiful as in the last case, where silver sutures had beenused. About three weeks after leaving the hospital theman returned to show himself, soundly healed. There wasstill plenty of hard material in the canal and around thering. The deep sutures had caused no discomfort what-ever, and nothing more has been heard or seen of them.Remarks by Mr. OwFN.-Not infrequently an atrophied</p><p>testis is found associated with an inguinal hernia; oftensuch a testis is imperfectly descended, and generally it is ofmore than doubtful physiological value. It might be con-sidered a good rule to remove such an imperfect gland whenoperating on a strangulated hernia, as by so doing thesurgeon is then enabled completely to blockade the inguinalcanal. The strong silver sutures which were used (asadvised by Sir Wm. Stokes) demanded subsequent dis-interment, whilst those of chromicised gut in the secondcase served their purpose perfectly. If suppuration occursabout deep sutures, the sooner the deep sutures are removedthe sooner the wound will heal.An important point is that neither of these men was</p><p>allowed to wear a truss after the operation. If the work of</p><p>the surgeon has been efficiently done no truss should b&amp;wanted; if a truss be applied, its pressure huriies on theabsorption of the plastic material which consolidates theweak region, and its application may thus militate againstthe success of the operation.</p><p>I have the pleasure of saying that the second case wa&amp;operated on by my house surgeon, Mr. J. J. Claike, whilst Iacted as his assistant.</p><p>BOROUGH LUNATIC ASYLUM, PORTSMOUTH.GENERAL PARALYSIS OF THE INSANE; ONSET IN FORM OF</p><p>STUPOR; APPARENT RECOVERY; RELAPSE, WITH EX-PANSIVE DELIRIUM AND SPEEDY DEATH; REMARKS.</p><p>(Under the care of Mr. J. D. MORTIMER, Assist, Med. Officer.)</p><p>J MR. MORTIMER expresses his obligation to Mr. W. C. Bland,medical superintendent, for permission to publish thefollowing notes.W. J. A----, aged forty-four, married, boiler-maker, was</p><p>admitted on Dec. 19th, 1885, with the following history. Hehad always been a steady hard-working man; was secretaryof a trade association, and had taken an active part in arecent Parliamentary election. No family history of anyneurosis. On Nov. 27th he had fallen, apparently accidentally,downstairs, striking the back of his head. On Nov. 30th, hewas first noticed to have a peculiar vacant look, and began totalk and act strangely, expressing an unfounded belief thathis accounts were " all wrong," turning out the gas at un-seasonable times, &amp;c. He gradually passed into the stateseen on admission. He was then described as a tall, gauntman, bald-headed, with a red beard; face sallow; expressionof vacant bewilderment; pupils equal, rather sluggish;. ,tongue slightly tremulous. No definite signs of thoracicor abdominal disease, but pulse small and weak. Totters inwalking; knee jerk brisk on both sides. No special rigidityor flaccidity of muscles. When questioned, he staredstupidly, giving no response, except that, when asked if hewas in pain, he said his " head was bad," and passed hishand over it. He spoke slowly, but otherwise normally.Two days after admission it was noted that the man had</p><p>slept well and fed and dressed himself (but slowly). "Sitsmotionless and silent, replying to questions tardily andbriefly. He generally answers those as to facts correctly&gt;but for some time persisted that the present year is1865."Four months after admission there had been no marked</p><p>change, but he was in all respects rather worse, being moredull and confused, more vacant in look and unsteady in gait,and often " wet and dirty" in habits. From this time(April, 1886) he steadily improved, at first in bodily, then inmental condition. At the end of May he was able to workin the garden, and at the end of June he was in good generalhealth, his pulse and gait being normal and the tremor ofthe tongue hardly perceptible. He conversed rationally andintelligently, the only noticeable fault being a slight slow-ness of mental operation.He was discharged on a months trial, which he spent in</p><p>the country, returning apparently well in all respects. Hewent back to work,.and for two months, according to thestatements of his wife and of those under whom he served,there were no signs of relapse. He seems, however, to havefretted rather unreasonably at having lost promotion by hisabsence, and not to have displayed much of his formeractivity of mind, At the end of this period he became rest-less and excitable, ordering expensive articles at shops andotherwise behaving insanely. After a few days he wasreadmitted to the asylum on Sept. 27th, 1886. He wasthen very boisterous and extravagant, wanting a specialtrain to meet the Prince of Wales, proposing to make alarge fortune by raffling watches, &amp;c. His pupils wereequal, gait unsteady, knee jerk brisk, tongue slightlytremulous, and there was well-marked hesitation and thick-ness of speech, which had only been noticed a few days.He continued in a state of acute excitement, often violentand destructive, sleeping but little; and although eating</p><p>I voraciously, he grew very thinand anaemic. On Dec. 1st. he had a slight attack of diarrhoea, and on the evening of. </p><p>the 2nd suddenly passed into a state of collapse. No, treatment had any effect, and he died on the morning of, Dec. 3rd, 1886.</p><p>Necropsy, twenty-four hours after death.-Calvaria of! normal thickness and densitv. Vessels of dura mater, shrunken. Sinuses contained fluid blood. Arteries at base</p></li><li><p>961</p><p>slightly atheromatous. Convolutions flattened and closelyopposed. Pia mater tough and anaemic. Decortication wellmarked over anterior and outer portions of frontal lobes,slightly around fissure of Rolando, hardly perceptible else-where. Choroid plexuses deep violet. Much fluid at baseof brain and in ventricles. Ependyma granular, especiallyin fourth ventricle. A small gelatinous clot in right cavitiesof heart; fluid blood in left auricle; left ventricle contracted.The thoracic and abdominal viscera generally showednothing noteworthy.Remarks.-Dr. Mickle states in his work on general</p><p>paralysis, that in the fe cases which set in with symptomsof stupor or pseudo-dementia, " the ordinary motor andsensory signs of general paralysis are either absent at firstor are masked," appearing in most cases when the extrememental symptoms pass off. "But not always; for amarked remission, or apparent recovery, may immediatelysucceed the acute symptoms, some weakness of the intellec-tual powers remaining." This case illustrates these state-ments, and perhaps also the tendency of technically"recovered" general paralytics to break down on return totheir ordinary course of life.</p><p>LEICESTER INFIRMARY.CASE OF VOMITING OF GALL-STONES; DEATH; NECROPSY;</p><p>COMMUNICATION BETWEEN GALL-BLADDER AND</p><p>DUODENUM ; REMARKS.</p><p>(Under the care of Dr. FRANK M. POPE.)L. H aged forty, married, was admitted on Sept. 3rd,</p><p>1887. Her general health had been fairly good; she hadnever had jaundice. Two years ago she had an attack of"pleurisy and inflammation of the bowels," and a similarattack six months ago. For the last two years she has hadoccasional cramping pains in the abdomen. Her presentillness began five weeks ago, when during the night she hadviolent pain in the abdomen, worse about the right hypo-chondrium. The pain was unrelieved by pressure, and easewas obtained only slightly by a mustard application. The nextday she began to vomit, and the pain became less violent.The vomiting has continued at frequent intervals ever since.She states that she is in the fifth month of pragnancy andhas had several children.State on admission.-The patient is a stout woman with a</p><p>fresh complexion. In the right hypochondrium there ismarked tenderness and a sense of resistance, but no tumour.Hepatic dulness not increased. The abdomen is slightlymore tender than normally, but nothing more can be madeout. There was no abnormal physical signs of heart orlungs. Urine: Sp. gr. 1010; alkaline ; contains no albumenor sugar. Tongue furred thinly, and rather dry. Bowelsnot open for two days. Temperature 94; pulse 70, feeble,regular. She was ordered a bismuth mixture every fourhours, and half a grain of opium in pill at the alternate fourhours. Diet to be milk, lime water, and ice.On the day after admission she was still vomiting con-</p><p>stantly. The vomit was green at times. No other change.On Sept. 5th, two days after admission, the note was:Last night she had a considerable increase of pain, accom-panied with slight convulsions and internal strabismus. Shewas not unconscious. She had nutrient enemata, withhalf an ounce of brandy in each, every four hours. Early thismorning she vomited two gall-stones of about five-eighthsof an inch in diameter, with six or eight facets on each, andseveral smaller ones. The pain continued. She was a gooddeal collapsed. Temperature 97 ; pulse very slow andsmall; bowels not open. All food and medicine by themouth were discontinued, and she had an effervescingmixture with three minims of dilute hydrocyanic acid.On the 6th she was in much the same state, and hadvomited a few more small stones. On the 7th the bowelswere freely opened, and the motions contained several gall-stones, one nearly three-quarters of an inch in diameter. Afew more small stones were vomited. She was taking essenceof beef, and a very little milk. After this she slightly im-proved, the vomiting almost ceased, and she began to take alittle more nourishment; but on the 17th she had anotherconvulsive attack and subsequent collapse, from which sheWas revived by hypodermic injections of ether. The vomitingnever entirely stopped, and on the 24th diarrhoea set in,and the nutrient enema.ta had to be stopped. On the 5ththe temperature was 100, the highest since admission ; Eihewas rather delirious, took little food, and the diarrhoea cun-</p><p>tinued. She gradually sank and died at 7.20 A.M. on the27th, twenty-four days after admission.Necropsy, thirty hours after death. - Body fairly well</p><p>nourished. Permission was obtained only for examinationof abdomen, on opening which nothing abnormal could beseen ; no general peritonitis, no excess of peritoneal fluid.Uterus reaching nearly to umbilicus. On raising the liverthe gall-bladder was found to be situated in a circum-scribed abscess cavity, formed by the adhesion of theneighbouring organs. The gall-bladder itself was in asloughy condition, and several ragged openings existed atits fundus; some small stones had escaped into the cavity.There was a circular opening half an inch in diameter, withwell-defined edges, leading from the gall-bladder into theduodenum, at about three-quarters of an inch below thepylorus. The common and cystic ducts were patent; one ortwo small stones were found in the duodenum. The stomachwas healthy, and there was no ulceration from the gall-bladder into it. The rest of the abdominal organs werehealthy, The total number of stones vomited weighed170 grains; those passed per rectum 103 grains.Remarks by Mr. POPE.This case is interesting for the</p><p>following reasons. It is an example of an exceedingly rarecomplication-viz., vomiting of gall-stones. Cases arementioned by Frerichs, quoting Morgagni, Hoffmann, Portal,and Bonisson. He expresses the opinion that stones maypass from the duodenum to the stomach, but does not seemto have well considered the matter. Murchison, quotingseveral authors and a few cases of gall-stone vomiting, saysthat a gall-stone of any size could not pass backwardsthrough the pylorus,l and describes a necropsy in which adirect communication existed between the gall-bla...</p></li></ul>


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