tember 1847, and from the local tenderness now experienced by the patient near the umbilicus, I was in hopes to have found the obstruction near the umbilicus, or in the right groin. In neither of these positions could I find any obstructing cause; and it was only by observing the pale, empty and contracted intestine toward the left side, that I was enabled to reach the true cause. Having ascertained the existence of an obturator hernia, I endeavoured to discover whether any tumour could be detected by an external examination below Poupart's ligament; but nothing of the kind could be felt, so that I may affirm, with confidence, that in this case, and at the same period of the symptoms, no evidence, or indication, or even suspicion of an obturator rupture strangulated could have been acquired from the existence of any tumour in the thigh. Obturator hernia strangulated may be considered a rare occurrence, and has been so little associated with the question of opening the abdomen to relieve internal strangulation, that I admit my attention was pre-occupied with the idea of discovering one of the more common causes of obstruction. If, however, the probable existence of an obturator hernia had occurred to me before, or at an early period of the operation, the ulterior intention of the operation might have been accomplished without exposing the patient to the risk associated with so prolonged an exploration as was found necessary, by at once introducing the hand into the pelvis, where the intestine might have been discovered passing through the obturator foramen. As I stated in the report of the case, the administration of metallic mercury was thought of but not employed; yet it is possible that the use of a considerable quantity might have been of service, from its weight sinking into the pelvis below the level of the obturator foramen, and by thus dragging upon the intestine it might have displaced it from its incarcerated position; so that I think, in a like case, provided it could be diagnosticated, metallic mercury ought to be had recourse to. In this case the secretion of urine was small in quantity; and this fact is, as far as I have seen, in accordance with previous observation, associated with the position of the intestinal obstruction; so that it may be stated that the nearer the obstruction may be to the stomach, the less will be the urinary secretion; with this diminished secretion of urine should be associated the great vomiting as one of its causes, which takes place in such a case. Whilst I think it right to attach some degree of importance to this urinary test, as one of the contributing means towards a correct diagnosis, and as an interesting physiological observation, yet I am anxious to admit that, in the instance before the Society, it gave no aid whatever in discovering the locality of the obstructing cause. The symptoms which the patient experienced in September were most likely not the result of an inflammatory attack, but of an obturator hernia on the right side. This inference may be arrived at by the negative indication of there being no post-mortem evidence of the result of any inflammation, and from the fact of there being ample room on that side for the entrance of a portion of intestine or omentum into the obturator foramen, which was very remarkably patulous. Reflecting upon all the associated circumstances of this case, I think it must be admitted there was no probability that any other means than those employed would have offered her any hope of prolonging her life, excepting the obturator hernia could have been discovered before the abdomen had been opened; and from what has been already stated, it is pretty clear that it could not have been so detected by external examination, and there were certainly no special or peculiar symptoms pourtraying its existence. It is evident this patient died from the effects of acute and rapid peritonitis, the result of opening the abdomen. Although in this case, as in my previous operation, the details of which are recorded in the last volume of the Transactions of this Society, the issue has been unfavourable, still I am strongly impressed with the propriety of making such attempts at relieving cases, which, if left to themselves and medicine, would almost certainly be fatal; and I am quite sincere in the belief that some few lives will be prolonged by persevering in the same operative procedure of opening the abdomen. THE HISTORY OF A CASE OF DISLOCATION OF THE HEAD OF THE FEMUR, BACKWARDS, WITH SOME OBSERVATIONS ON THAT FORM OF DISLOCATION. BY RICHARD QUAIN, PROFESSOR OF CLINICAL SURGERY IN UNIVERSITY COLLEGE, LONDON; Received June 27th-Read June 27th, 1848. OPPORTUNITIES of ascertaining, by dissection, the exact position of the bones and the condition of the surrounding soft parts in cases of dislocation, especially those of recent occurrence, are so infrequent, that every example of the injury examined under such circumstances becomes a study of value to the practical surgeon. It is on this account that I venture to bring under the notice of the Society a case of dislocation of the femur, at the hip joint, which I dissected soon after the accident by which the bone was displaced, and without any attempt having been made to restore the bone to its natural position. Maurice Coghlan, ætat. 60, a stout man, employed as a bricklayer's labourer, while carrying a burden up a ladder, when he had ascended about thirty feet, was observed by one of his fellow-workmen to pause, and then instantly to fall to the flagged court on which the ladder rested. He was taken VOL. XXXI. |