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I confess, however, that I have been disappointed with the results of my attempts to cure congenital hernia in children by Mr. Wood's operation with pins used subcutaneously. Either I did not succeed in pushing them through the anatomical structures I intended, which is so easy to do in the adult with the strong curved needle, or I failed to lock them, and twist them as it is necessary to do; but, from whatever cause, in the two cases on which I operated the result was unsatisfactory. The hernia came down as soon as the pins were taken out.
I determined, therefore, to perform an operation consisting of opening the sac and obliterating the canal by the introduction of strong sutures. The steps followed will be best understood by the report of a case which formed the subject of a clinical lecture,
Robert Inglis, aged sixteen months, was the subject of congenital inguinal hernia, which was observed shortly after his birth. It was small when first noticed, but soon increased in size ; and it had grown with his growth. It was on January 9th, 1879, about the size of a turkey's egg, and distended the left side of the scrotum. It could be reduced with ease; but it was easily slipped down, and no aparatus or bandage could retain it in its place. Trusses had been tried at various times ; but no sooner did the child move than the hernia came down. On returning it into abdomen, the fingers was rapidly pushed through the inguinal opening; but even then, unless pushed far up, the bowel slipped down alongside of it.
Before performing any operation, I accustomed the little patient to the pressure of a bandage. I returned the bowel, and applied a large thick pad, which was bandaged very firmly with figure-of-eight-bandage round the groin. This retained the hernia in its place for some hours; but the movements of the child and repeated fits of crying brought it down usually within twenty-four hours.
On January 25th, 1879, I performed a radical operation as follows: The patient having been put under the influence of chloroform, the rupture was returned and kept up by the finger of an assistant. A longitudinal incision was made along the
whole length of the sac, from opposite the internal ring to the bottom of the scrotom, this divided all the textures down the peritoneal sac, which, as usual, had been thickened by the presence and movements of the hernia. With the handle of the knife and a few touches of its point, I separated the sac from its superficial structure, leaving the posterior part lying over the cord, which was seen behind. I now divided the sac into two halves by a transeverse cut, except at the back, where it was adhering to the cord. One half was folded down over the testicle, so as to form a sort of tunica vaginalis. The upper half was rolled into a sort of ball or plug which I pushed into the internal abdominal ring and had it kept there by the assistant. I now approximated the walls of the inguinal canal much in the same way as in the wire operation for the radical cure of hernia in the adult. The superficial structures having been previously pushed aside and slightly dissected from off the abdominal aponeurosis, the relations of the rings and the canal could be felt and in great part seen. I took a strong nævus-needle and pushed it through the external pillar of the canal at a spot opposite the internal ring; then guiding it with the point of my left forefinger lying in the internal ring, I made it lift up the lower border of the internal oblique muscle, and emerge through the internal pillar of the external aponeurosis about half an inch above its lover edge. A strong waxed silk thread was now passed through the hole at the point of the needle, which was then withdrawn, pulling the thread with it. The thread was then tightly tied, including the structures through which the needle had been passed, and so fixing into the internal ring the rolled-up bit of the sac, care being taken that the external raw gurface of the sac should be turned outwards toward the integument which was to cover it. A little below the first stitch, a second was introduced in the same direction, care being taken to avoid the structures of the cord, which lay at the bottom of the wound, The edges of the external ring were now drawn together tightly above the cord by a strong silver wire ; this was made to take a very strong hold, by passing the needle first through the external pillar across the ring, and through the internal pillar. In making the internal puncture, I passed the point of the needle so far towards the linea alba as to make it pierce from below the tendon of insertion of the rectus muscle, so as to give a firm hold. When the wire was drawn through with the needle, it was clamped, so as to squeeze together the boundaries of the external ring; and it was retained in that position by a little rod of silver with a hole at its point, through which the two ends of the wire were passed ; and having been drawn tight, they were fixed by a turn round the rod. The silk threads were clipped short; and the wires with the little clamping rod, to which they were fixed, were allowed to hang out at the bottom of the wound. The edges of the incision were now united with thin silver-wire sutures, and the wound dressed with antiseptic precautions. The child was placed on a St. Andrew's cross, the upper arms of which were joined by a sheet of calico on which the body rested ; the legs being securely bandaged with strips of adhesive plaster to the lower limbs of the cross. The pelvis and chest were also securely fixed to the apparatus. In this way, the movements of the child were effectually controlled.
Two days after the operation the scrotum was swollen, as if a portion of hernia had escaped from beneath the bandages ; but this proved to be only a soft fluctuant swelling, probably an effusion of serum into the artificial tunica vaginalis, which had been formed by the folding down over the testicle of the lower half of the hernial sac, as described in the operation. In two days, this swelling had disappeared, and the scrotum was in its natural state. On the fourth day after the operation, the wound was dressed. It was found almost united, except in the place where the wires were left hanging out.
hanging out. On the tenth day, the little clamp and wire were removed, and the parts were found quite matted together.
It is unnecessary to detail the further progress. The dressings were changed every two days, and at the end of four weeks cicatrisation was practically complete. The child was then freed from restraint; but, for precaution, a bandage was still applied round the groin.
May Ist. At this date, the radical cure of the hernia is perfect. No amount of exertion either of the limbs or on crying has the slightest effect on the inguinal region of the abdominal walls.
The result has exceeded my expectations, and I shall not hesitate to practice the operation in all similar cases, and even to adopt it as a means of accomplishing a radical cure in cases of strangulated hernia in which an operation for the relief of strangulation has become necessary.— British Medical Journal.
Edema of the feet occurring in Typhoid Fever-in connection with Abscesses in thigh and lumbar region).—By Dr. CUFFER, “ Interne des Hopitaux,” (condensed from la France Medicale).-Abscesses in the thighs, lumbar and sacral regions are frequently met with as sequels of typhoid fever. They are due, no doubt, to prolonged and enforced dorsal decubitus. They are either superficial or deep, and contain pure pus or a mixture of pus and blood, the latter the result of the breaking down of small sanguineous tumours. As a rule they are about the size of a small nut, but occasionally large collections of pus are met with which have taken their origin from the coalescence of smaller ones. These little collections are sometimes very difficult to detect, the ordinary symptoms of suppuration being marked by those of the disease. The sign the writer draws particular attention to is cedema of the feet, which always accompanies this pus formation, and is a certain guide to its detection. It is entirely a distinct thing from phlegmacia dolens. He cites from cases in which slight oedema of the feet led to the abscesses in the thighs and lumbar regions.
Medical Tariff in Germany.-According to the Augsburg Gazette, the minster of public instruction in Prussia, has submitted to the Society of Medicine at Berlin, a scheme for fixing the remuneration of medical men. This is the Tariff:
1. For the first visit to a patient 2 marks, (one German mark is equivalent to 1 franc, 25 centimes.)
2. For every subsequent visit, 1 mark.
If there should happen to be more than one patient under the same roof, the fee for each subsequent patient shall be 1 mark.
3. For consultation with one or several practitioners. For the first consultation, 5 marks, for each snbsequent consultation, 3 marks.
4. For office consultations : First consultation 11 mark, 5. Subsequent consultations of a mark.
6. Attendance from 10 P.M., to 7 A.M,, three times the fee fixed in (1) and (2), and double the fee in (3) and (5).
7. For an examination with the ophthalmoscope, larynogoscope or other diagnostic instrument, 2 marks.
8. For admininistration of Chloroform, for diagnostic purposes, 3 marks.—Le Progres Medicale, 29th March, 1879.
Belladonna in the Treatment of Intestinal obstruction.-Dr. NORMAN KER reports five cases of intestinal obstruction which have been cured by the administration of large doses of belladonna. The treatment consisted in giving one or two grains of belladonna every hour, together with opiate fomentation to the belly and warm applical tions. Nearly all the patients were in a dangerous condition, but were entirely cured, the remedy taking effect in six to nine hours. One patient took 16 grains of the extract. The author gives no precise account of the cause of the obstruction.The Practitioner.
Rare Anomaly-Single Kidney.-A rare anatomical curiosity was found at the autopsy of a patient who died of typhoid fever, in the practice of Dr. Crocq, of at St. John's Hospital, Brussels. There was no right kidney. The left kidney was generally hypertrophied, weighing 420 grammes. It occupied its usual place in the abdomen. A mass of connective tissue the size of a small nut represented the right kidney. The renal vessels on the left side were large, those of the right merely rudimentary.-Condensed from the Presse Medic., belge of 24th March, 1879.