CASE

OF

OBTURATOR HERNIA,

SIMULATING INTESTINAL OBSTRUCTION WITHIN THE

ABDOMEN;

TO RELIEVE WHICH GASTROTOMY WAS PERFORMED.

BY JOHN HILTON, F.R.S.,

ASSISTANT-SURGEON TO GUY'S HOSPITAL.

Received June 26th-Read June 27th, 1848.

MISS aged 36 years, a tall, thin person, and in delicate health, had an attack of vomiting, with constipation of the bowels, in September 1847, which, after continuing four or five days, yielded at that period to the effect of aperients with laxative injections, and the application of leeches and fomentations to the seat of pain in the right inguinal region, above Poupart's ligament. Since that time she has frequently had pain in the bowels of a spasmodic character, which has been relieved by her taking brandy and water. The bowels have been generally constipated.

On the morning of Thursday, January 20th, without any obvious cause, she had an attack of vomiting, which continued, with intervals of relief, until 11 P.M.

When Mr. Blackmore, surgeon, of Old-street Road, first saw her, no hernia was perceptible; there was not any pain on pressing the abdomen, nor was there any distention of it. The pulse was 84. She had taken castor-oil twice, and rejected it each time. Mr. Blackmore ordered a large

mustard plaster to be applied over the stomach, two grains of calomel and five of ext. coloc. co. to be taken every two hours with some effervescing medicine.

21st, Friday-10 A.M.-Much the same; no action of the bowels; the vomiting continues; pressure upon the abdomen relieves somewhat the spasmodic pain; an aperient injection to be used, and one-half drop of croton-oil added to the pills. 8 o'clock P.M.-No change in symptoms, except more pain around the umbilicus, at which part eight leeches are to be applied, and their application to be followed by a warm-bath; the aperient pills to be omitted; one grain of powdered opium to be given at night.

22nd, Saturday-10 A.M.-Has had some sleep and is more free from pain, and there is less frequent vomiting: pulse 84. Omit all medicine, and give a little fluid nourishment. Secretion of urine scanty but healthy. Fomentations to abdomen. 9 P.M.-Continues much the same as in the morning; an aperient injection to be administered.

23rd, Sunday-10 A.M.-Is in about the same state as yesterday. 9 P.M.-Dr. Fox met Mr. Blackmore in consultation. Pulse 96. Tongue more dry. Slight hiccough. Has vomited fæcal matter several times to-day; no distention of the abdomen, and but little pain on pressure. Apply mustard plaster, followed by large linseed-meal poultices over abdomen, and give calomel gr. x., with one grain of powdered opium at night. Discontinue other means.

24th, Monday-9 A.M.-Has passed a good night; symptoms much the same in other respects. 10 P.M.-Has had no vomiting nor any action of the bowels: repeat the opiate, with calomel gr. v.

25th, Tuesday-10 A.M.-Has not passed a good night; vomiting has returned with occasional hiccough; tongue more dry in centre; pulse 108. A blister to be applied at the only painful part of the abdomen, namely, the left side of the umbilicus; this to be followed by a linseed-meal poultice omit the opium, as it made her sick the last time she took it.

26th, Wednesday-10 A.M.-Has had a good night, and appears upon the whole better. Vomiting much diminished. An injection of castor-oil brought away some fæculent matter from the bowels; continue to give nourishment in small quantities, and discontinue medicines.

From this time until Saturday night, the 29th, she continued in the same state, when Dr. Fox saw her again, in consultation, and ordered small doses of hydrochlor. morphiæ every two hours, and the lower bowel to be stimulated by a small turpentine injection in the morning. The morphiæ retained; the injection did not cause any sickness, nor did it give any relief to the bowels. She expressed herself as feeling better, notwithstanding the fatigue occasioned by the injection.

31st-9 A.M.-She has not had any vomiting during the last forty-eight hours; no increase of pain in the abdomen, but no relief from the bowels: the pulse is 120, soft; tongue moist, and clean at the edges.

At this period I was requested to see the patient, in consultation with Dr. Fox and Mr. Blackmore.

The patient was lying upon her back; the face was thin, with a distressed aspect: tongue dry and brown, its centre furred on either side; breath very offensive, smelling like fæculent matter: pulse 120, small. The abdomen was soft, somewhat pliant, and but little distended; neither gentle pressure upon the abdomen, nor the examination by concussing it, produced much pain. On pressing deeply on any part below the level of the umbilicus the patient complained, and more especially so about an inch to the left of the umbilicus. The abdomen was very resonant over all the gastric and intestinal portion of the abdomen, excepting below the umbilicus, where it was chiefly dull on percussion, although there were portions of that surface quite resonant. Every now and then the whole surface of the abdomen became remarkably retracted, uneven, and quite undulatory or wavy, during which time the patient experienced spasm of the belly, and the course of the subjacent convolutions of intestines could be distinctly felt and seen. This condition

lasted about a minute, or less, then subsided, and again returned after a lapse of several minutes. No hernia could be detected. Whilst at the bed-side she vomited the fæculent contents of the small intestines, well coloured with bile, and looking more red than natural. The quantity of urine secreted had been very small, about four ounces in the preceding twenty-four hours.

On consulting, we could come to no other conclusion than to consider this a case of mechanical obstruction in the small intestine, and one which offered no hope for the patient by any means short of opening the abdomen. That the obstruction was not in the large intestine might be legitimately inferred from the abdomen not being much distended, from the capability of the colon to retain nearly three pints of injection without distress, from the vomiting having come on so carly in the attack, and from the secretion of urine being very scanty.

It had been suggested that metallic mercury should be administered; but ultimately, on reflection, it was not employed. Guided in part by the history of the symptoms which occurred last autumn, our impression was, that the cause of the obstruction would be found either to the right of, or rather lower than, the umbilicus, where the chief pain was at that time experienced, or to the left of the umbilicus, where deep pressure now produced some pain.

After explaining to the friends of the patient, and to the patient herself, her then condition, and her prospect, without something could be done by surgical means; and letting her understand that the inhalation of chloroform would cause her to experience but little, if any, pain during the operation, the patient herself and her friends acquiesced in our suggestion to explore the abdomen the next morning, provided no manifest improvement should intervene. Two or three doses of morphia were prescribed to be administered during the night, and directions were given for the house to be made as warm as possible, and to be kept so. On the following morning, no important improvement was observable in the

patient's symptoms, but there had not been any vomiting during the night, and she had had some sleep. The tongue was more extensively dry. The pulse about 120 in the minute; the abdomen more prominent; the breath still of a fæculent odour.

The catheter was introduced, and about an ounce of urine abstracted. The hair was shaved off the pubes. The patient's head and shoulders were raised, and under the thighs was placed a large pillow, so as to relax as much as possible the abdominal walls. Chloroform was then administered by Dr. Gull. A napkin was folded into the form of a hollow cone, with the apex open, a piece of sponge was placed within it, and the chloroform poured upon it. This was held over or allowed to rest upon the patient's face so as to cover the nose and mouth, and in about two minutes, the insensibility appearing to be complete, I began my incision at the umbilicus, but the patient evidencing some sensibility I did not proceed for about another minute. I then continued the incision downwards to near the pubes, cutting through skin and cellular tissue and numerous small veins, so as to expose the median line of tendons. The natural colour of the tendinous structures and the more opaque line of the linea alba were obscured by blood, and when the vertical median section was extended into the parts then exposed, it divided the linea alba in part only, and opened also the sheath of the left rectus; so that it was clear the linea alba was somewhat deflected from its normal course. Two little arteries required ligatures. When all bleeding had ceased, the peritoneum was opened near the umbilicus, and its division completed downwards upon a broad director. A small quantity of serous fluid, coloured with blood, flowed from the peritoneum. The small intestines, somewhat distended and presenting numerous small red ecchymosed spots of inflammation upon them, occupied the opening. On introducing the hand into the peritoneum to ascertain the cause of obstruction, nothing abnormal could be detected. As it was now my wish to get a view of empty intestine I found the opening I had made was not long