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§ V.-LIGAMENTOUS BAND CONFINING A PORTION OF

INTESTINE TO THE MOUTH OF A HERNIAL SAC.

CASE XXXV.-A man, aged 53, May 1814, was affected with vomiting and uneasiness in the bowels, which seized him in the following manner. The attack commenced with a feeling of commotion, or, as he termed it, “ a working," which began at the lower part of the belly, towards the left side; it moved gradually upwards, till it reached the stomach, and then he vomited almost every thing he had taken since the last attack. He was affected in this manner, at uncertain intervals, several times a-day, and the complaint had continued about a fortnight. He had been for fifteen years affected with a small hernia of the left side, which often came down, but was easily reduced. He had never used a truss until a few weeks before I saw him. From that time his hernia had never appeared, but very soon after he applied the truss the above mentioned complaint began. There was no fixed pain in the belly; his pulse was natural; his bowels were confined, but motions were procured by medicine. For a month after I saw him first, he continued to attend to his work. He was then confined to his house, and soon after to bed, with increasing debility and emaciation; and he had frequently violent paroxysms of pain in the abdoThe other symptoms continued as before. His hernia never appeared; the pulse was natural; evacuation from the bowels was procured by medicine. He died of gradual exhaustion, about ten weeks from the commencement of the vomiting.

Inspection.-The hernia was found to have been femoral; a portion of the sigmoid flexure of the colon ad

hered to the mouth of the sac, and a fine ligamentous band, connected by both its extremities to the mouth of the sac, surrounded the intestine at this spot, but without producing any diminution of its area; and the coats of the intestine were healthy. There was intus-susceptio in two places of the small intestine; and the lower part of the ileum was inflamed. The colon was collapsed; the pylorus was hard, and a little thickened; and the inner surface of the stomach at the pyloric extremity was considerably eroded.

SECTION III.

ILEUS WITH MECHANICAL OBSTRUCTION, OR OTHER ORGANIC CHANGES IN THE STRUCTURE OF THE PARTS.

§ I.-OLD DISEASE OF THE INTESTINE CONNECTED WITH

HERNIA AND ARTIFICIAL ANUS.

CASE XXXVI.-A lady, aged about 60, had twentyseven years before her death suffered from strangulated hernia, which terminated in artificial anus in the right groin. This continued open for a very considerable time, and then gradually closed. Ten years after this, she had another attack, which was reduced without operation; but, from this time, she had been liable to attacks of pain in the abdomen, accompanied by obstruction of the bowels. It was in one of these attacks, more violent than usual,

and which had not yielded to the usual remedics, that I saw her along with Mr. Young on the 12th March 1827. There were then severe pain and tension of the abdomen, urgent vomiting and obstinate costiveness; the pulse little affected. In the right groin the cicatrix left by the artificial anus was very obvious; a small puffy tumour protruded from beneath the crural arch, which could be reduced without any difficulty; and the aperture felt quite free.

This severe case having resisted every remedy for four days, and the patient's strength beginning to give way, it was determined, in consultation with Dr. Ballingall, to attempt her relief by an incision in the seat of the cicatrix. This was accordingly made by Dr. Ballingall in the evening of the 15th. The incision laid open an old hernial sac, which adhered intimately to the surrounding parts, and a small quantity of serous fluid was discharged from it. Towards the outer side of the sac, there lay a substance scarcely exceeding a third of an inch in diameter, descending from beneath the crural arch, and attached closely by its extremity to the bottom of the sac. It was entirely without strangulation-the passage around it beneath the arch being entirely free on all sides. This body, on farther examination, was found to be a small finger-like process of the intestine, and had evidently formed the communication betwixt the intestine and the artificial anus,—the extremity of it being closely attached to the cicatrix. It had been accidentally opened in making the first incision, and was afterwards more freely laid open; and the finger introduced by it, could be freely carried into the intestine, in every direction, without any feeling of obstruction. No relief followed the operation; the symptoms continued unabated, with stercoraceous vomiting; and the patient died on the 16th-eighteen hours

after the incision. No discharge had taken place from the opening during all this period.

Inspection. The portion of intestine laid open in the operation was found to be in the lower part of the ileum; and a small process, or appendix, went off from one side of the intestine at the part, and descended into the hernial sac. The coats of the intestine were somewhat thickened, both above and below this spot, but there was very little sensible diminution of its area. Above the diseased portion, the intestine was greatly distended, without any remarkable change of colour or structure. It contained only air and liquid feces; and no obstacle appeared to the free discharge of these by the orifice in the groin, for the feculent matter began to flow freely during the dissection.

§ II-INTERNAL HERNIA.

CASE XXXVII.—A gentleman, aged 25, on 8th August 1821, was seized with pain in the abdomen, and other symptoms of ileus, for which he was treated by Dr. Macaulay in the most judicious and active manner, but without relief. I saw him on the 10th; his pulse was then 96 and weak, and his countenance exhausted. The pain had subsided; there was no tumefaction of the abdomen, and he bore pressure over every part of it; but there had been no stool. On the 11th and 12th there was no change, except some very slight evacuations by injections. On the 13th, the pain returned with great violence in the abdomen, with vomiting and rapid failure of strength, and he died in the night.

Inspection.-The whole tract of the small intestine was greatly distended, and there was superficial inflammation

in many places. About three inches from the caput coli, a turn of the ileum about three inches in extent was strangulated and gangrenous; and the strangulation was produced by a firm ligamentous band, which came down from the omentum, and was firmly attached to the parts about the brim of the pelvis.

CASE XXXVIII.-A girl, aged 17, was seized, on the 5th of July 1818, with violent pain and tenderness of the abdomen, vomiting and obstinate costiveness. Various remedies were employed for four days without relief. I saw her on the 9th; the abdomen was then enormously enlarged, tense and tender; there had been no evacuation of the bowels; the pulse was feeble and rapid; and she died at night.

Inspection. The small intestine was much distended and inflamed; and in several places it had burst, and discharged thin feculent matter into the cavity of the peritoneum. At the root of the mesentery, on the right side, and on a line with the head of the colon, there was a mass of diseased glands the size of a large egg. To this mass the appendix vermiformis adhered very firmly by its apex, and, as it stretched across betwixt this tumour and the caput coli, it left beneath it a space which admitted three fingers. In this space, a turn of intestine, six inches in length, was strangulated and gangrenous.

CASE XXXIX.-A man, aged 28, was seized with the symptoms of ileus in the usual form, on the 15th of August 1815, and died on the 18th.

Inspection. There was a hard glandular mass of considerable size formed in the mesentery. To this mass several turns of intestine had contracted adhesions of long standing, and the calibre of the intestine, at several of

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