KILGOUR, ALEXANDER, M.D., one of the Physicians to the Aberdeen Infirmary. MACLAGAN, DOUGLAS, M.D., F.R.S.E., Surgeon to the Royal Infirmary, Lec- MILLER, JAMES, F.R.S.E., Professor of Surgery in the University of Edinburgh. REDFERN, P., M.D., London, Lecturer on Anatomy and Physiology, and on His- ROBERTSON, WILLIAM, M.D., F.R.C.P., Physician to the Royal Infirmary, SIMPSON, J. Y., M.D., F.R.S.E., Professor of Midwifery in the University of SYME, JAMES, F.R.S.E., Professor of Clinical Surgery in the University of OCT 25 1886 ARTICLE I.-Case of Hernia, strangulated within the Abdomen, and remedied by Operation. By JAMES SYME, Esq., Professor of Clinical Surgery. THE reduction into the abdomen of a hernial sac, with its contents in a state of strangulation, is an occurrence so rare in the practice of surgery, that systematic teachers and writers generally seem to regard it as a subject hardly deserving of their notice. Mr Teale, of Leeds, in his excellent work on hernia, has collected and presented in a tabular view all the cases of this kind which have been recorded by Arnaud, Dupuytren, and, more recently, Mr Luke, of London, from which it appears that the only instances of an operation performed with success, under such circumstances, in Great Britain, are one recorded by the last-mentioned gentleman, and another by Mr Wade. I have several times been asked to see patients on the point of sinking under the effects of this "reduction in mass," as it is termed by the French surgeons; and on two occasions have had an opportunity of examining the parts concerned, after death. The stricture caused by the neck of the sac was then so obviously the cause of death, and might have been so easily remedied by incision, that the non-performance of an operation within due time seemed matter of deep regret, and suggested as an imperative duty to operate whenever the grounds of suspicion should warrant this proceeding. Upon the 13th of October last, I was asked by Mr Sidey and Dr Newbigging to see a patient, who appeared to be suffering from an NEW SERIES.-NO. I. JANUARY 1850. A internal strangulation of the bowel. He was a man about fifty years of age, the butler of a family in town; stout in frame, and rather corpulent. For eleven years he had been troubled by an inguinal hernia of the right side, and worn a truss to prevent its protrusion, until the last six weeks, during which he had not observed any swelling, although the bandage had not been used, in consequence of five months having elapsed without any appearance of it. At twelve o'clock of the preceding night, he had suddenly felt very ill, and sent for Mr Sidey, who saw him at one o'clock in the morning, complaining of intense abdominal pain, with quick pulse, cold perspiration, and vomiting. Upon careful examination, a tumour, about the size of a hen's egg, was felt in the right iliac region, without any external enlargement or thickening of the parietes of the cavity. Leeches were applied, and several injections administered during the night, with some palliation, but no material alteration, of the symptoms; which continued much the same as they have been described, until we met about two o'clock in the afternoon-fourteen hours from the commencement of the attack. As there could be no doubt that strangulation of the bowel existed, we examined the suspected region with all the care in our power, but, probably from the abdomen having become more distended, without being able to detect the tumour which had been felt the night before. All that we could perceive was a slight degree of induration or resistance, opposite the internal ring, over a space not much larger than the point of a finger. In these circumstances I should not have felt justified in undertaking any operation, unless Mr Sidey's accuracy of observation had been well known to me, and, in absence of any positive information that could be obtained at the time of our examination, rendered his detection of a tumour in the first instance sufficient ground for surgical interference. Having placed the patient in a convenient position, I made a free incision of the integuments throughout the whole extent of the inguinal canal, tied the superficial epigastric artery, which had been cut, inserted my finger through the external ring, and guiding upon it a probe-pointed curved bistoury, divided the aponeurosis of the external oblique, up to the internal opening for the cord. There being still no appearance of a tumour, but a more distinct feeling of resistance, I divided the other coverings of the cord, and brought into view a dark-coloured mass, at the internal ring. Pulling this toward me, I readily drew out a hernial sac, about the size of a hen's egg, which, being opened, was found to contain a portion of the small intestine. Searching for the stricture, I encountered a difficulty from the sac yielding to the slightest pressure, and returning with its contents into the abdomen. I, therefore, seized it with a pair of forceps, and thus obtained the requisite tension, until I succeeded in passing the edge of my nail beyond the stricture, and guiding the bistoury upon it, effected the dilatation necessary for accomplishing reduction of the strangulated part. The patient was speedily relieved from all his distress; and, although a very unfavourable subject for any operation, through the kind and judicious management of Mr Sidey, recovered completely, and is now quite well. There seems to be considerable difficulty in satisfactorily accounting for the strangulation. It was evidently caused by the neck of the sac; but whether the hernial pouch had remained empty until the symptoms were produced by the entrance of intestine, or whether the contents had previously been in a state of incarceration, is a question that admits a difference of opinion. Mr Sidey informs me that, about three weeks before the operation, the patient suffered for two or three days from colic pains, but not of such a character as to suggest the suspicion of hernia; and the stricture was so extremely tight that I can hardly suppose the intestine could have been imprisoned, without affording signs of being so. This case will, I trust, afford encouragement to operate for the remedy of hernial tumours, reduced in a state of strangulation; and may also be regarded as possessing some interest from being, so far as I know, the only instance of recovery from a hernia which has become strangulated within the abdomen. ARTICLE II.-On the Detection and Treatment of Intra-Uterine Polypi. By J. Y. SIMPSON, M.D., Professor of Midwifery in the University of Edinburgh.-(With four Plates). AFTER a polypus, or pediculated tumour, arising from any part of the interior of the uterus, has once passed downwards into the vagina, the diagnosis of the disease is, generally speaking, very easy, the operation for its removal comparatively simple, and the result of the treatment in the highest degree successful and satisfactory. But before a uterine polypus has passed through the os uteri -in other words, as long as it is still intra-uterine, or shut up and contained within the uterine cavity-the disease has hitherto been usually regarded and described as entirely beyond the reach of legitimate diagnosis and treatment. "It very frequently happens," observes Dupuytren, "that polypi concealed in the uterine cavity, inaccessible to our senses and instruments, give rise to severe symptoms, the true cause of which cannot be determined."1 "When polypi," he again states, "are entirely included within the uterus, the rational symptoms afford room only for conjecture; and examination by the finger or speculum are both alike insufficient." 2 "So long," remarks Madame Boivin, "as the polypus is concealed within the uterus, all that can be ascertained is the increased size of that 1 Leçons Orales, vol. iii., p. 542. 2 Ibid, p. 490. 1 " 3 organ." "If the polypus," says Dr Ramsbotham, "be still included within the uterine cavity, and if the mouth of the organ be closely shut, it is impossible to reach it by the finger, and consequently quite out of our power to ascertain its presence.' "So long," according to Mende, "as a polypus is enclosed in the uterine cavity, its diagnosis is scarcely possible.' "True uterine polypi, while they remain enclosed in the uterine cavity, furnish," observe Roche and Sanson, "none but equivocal symptoms, which may be confounded with those of pregnancy. These different symptoms may also depend on chronic inflammation of the womb; and it is often impossible to distinguish this affection from polypus. In the actual state of the science, there is but one case in which a certain diagnosis may be formed-viz., when the neck being effaced, and partly opened, it is possible to feel the rounded tumour within."4 These, and other passages that might be cited, show that intrauterine polypi are generally considered at the present day as placed beyond the pale of any certain means of detection, or any possible means of operative removal. And some of the older pathologists, indeed, would seem to have believed that there was no necessity for devising such means, inasmuch as, in their opinion, no danger was connected with the disease as long as the polypus remained intrauterine. They held that the great source of prostration and peril attendant upon uterine polypi-namely, the hemorrhage or menorrhagia which accompanies them-is not liable to supervene, till the polypus has passed through the os uteri. Levret, for instance, was of opinion that, as long as a polypus remained within the uterine cavity, there was no accompanying hemorrhage, and that floodings appeared only after the tumour had left the uterine cavity.5 Several years ago, I saw, with Dr Alexander Wood, a case, the result of which was distressingly opposed to this doctrine. CASE I. The patient was about fifty-five years of age, and unmarried. She had been suffering long under severe menorrhagia. The face was pale and anæmic, and her health and strength broken down. On examining, per vaginam, the os uteri was found closed; but the uterus felt somewhat large and distended; and Dr Wood believing, with me, that the hemorrhagic drain which was present might be the result of an intra-uterine polypus, the mechanical dilatation of the uterine cavity was advised, but given up, in consequence of local treatment being objected to. In a few weeks the patient sunk, under the continuance of the hemorrhage. On opening the body, Dr Wood and I found the lower part of the cavity of the uterus distended by a polypus, of the size of a small plum, and attached to the back wall of the uterus by a narrow half-broken stalk. The lining membrane of the uterus was white and 'Practical Treatise on Diseases of the Uterus. Heming's Translation, p. 200. 2 Medical Gazette, vol. xvi., p. 406. 3 Krankheiten des Weibes, p. 591. 4 Nouveaux Elémens de Pathol. Med. Chir., tom iii., p. 284. 5 Levret-Sur la Cure Radicale de Plusieurs Polypes de la Matrice, p. 25, &c. &c. |