Notes of Cases. By Geo. W. Brown, M. D., Port Carbon, Pa.
CASE I.—STRANGULATED HERNIA.
I was called to see Mrs. II., a tall, spare woman, 59 years
of age, a native of Scotland, January 9th, 1852. I found her
complaining of severe pain in the right groin, and extending from
that point over the whole abdomen; a constant desire to go to
stool without being able to pass anything from the bowels; fre-
quent vomiting of a dark green, bilious matter; tongue very much
coated with a thick yellow fur; constant thirst with a desire for
cold drinks; pulse about 100, small and weak; skin warm and
moist, and the countenance anxious and dejected. On examining
the abdomen I found it a good deal distended and tympanitic,
and slightly tender to the touch, and in the right groin a large
hernial tumor. The history she gave of her case was, that
twenty years previous, while in Scotland, she was assisting to
take in some hay, and while in the act of raising a large forkful,
she felt something give way in the right groin, and a few days
after she discovered a small tumor there, -which disappeared upon
slight pressure, but had re-appeared after a long walk or a hard
day’s work ever since, but always disappeared on going to bed,
relaxing the muscles and making gentle pressure upwards. About
ten years since, while in Scotland, it became strangulated, but
was relieved by purgatives and opiates. Latterly it had become
more troublesome, coming down oftener, and being more difficult
to return, as well as more painful when it was down. This
morning, immediately after she arose, she was seized with the
symptoms enumerated above, which have continued pretty much
the same throughout the day, sometimes abating in severity a
little and then returning more severely. Every attempt to swallow
anything, even the blandest liquids, produces vomiting. The
pain has been considerably abated by pretty large doses of the
tinct. opii, which she has taken, and the application of warm
fomentations to the tumor. I placed my patient in the proper
position, and made use of the taxis for a short time, but very
soon desisted in consequence of the pain it gave her. I directed
her to have opium 1 grain, calomel gr. iij. every three hours,
the warm fomentations to be continued to the tumor, and a tur-
pentine liniment to the entire surface of the abdomen.
Jan. 10«A, 10 A. M.—Patient passed a very good night, less
vomiting and less pain. Gums touched by the calomel, pulse
small and weak, skin bathed with warm perspiration, abdomen
tympanitic but less painful to the touch, tongue less coated and
countenance less dejected. I again tried the taxis, but was again
obliged to desist in consequence of the pain it gave the patient.
Directed a warm bath every 6 hours, the liniment and the fo-
mentations to be continued in the intervals. Opium gr. 1
every four hours, without the calomel, and large injections of
warm water every four hours, so as to distend the colon to its
utmost extent.
Jan. lltA, 10 A. M—Patient passed a very good night, passed
some wind from the bowels but no feculent matter. All the
symptoms are relieved, no pain, and scarcely any sickness of the
stomach, mouth very sore, teeth all loose, tumor less tense and
less painful to the touch, pulse fuller and stronger and the coun-
tenance somewhat cheerful. Continue treatment, with the addi-
tion of light nourishment. My patient continued to improve
(excepting that she passed no feculent matter from the bowels)
up to the morning of the 15th, when she was again seized with
violent pain and vomiting, which soon became stercoracious. The
pain commenced in the tumor, but soon extended over the entire
abdomen, which soon became very tympanitic and very tender
to the touch. In the evening I told her that nothing but an
operation would relieve her, to which she said she would submit,
if no better, by moi'ning. I directed one grain of morphine every
four hours, and left.
Jan. 16th, 10 A. M.—Countenance sunk and anxious, skin
cold, pale, shrunken and covered with a greasy perspiration,
pulse small and thready, patient unable to articulate so as to be
heard, unless the ear is placed close to her mouth. Increased
tympanitis, but less pain. She readily consented now to an ope-
ration, and Dr. D. J. McKibbin having been called in consulta-
tion, readily agreed with me as to the necessity of operating im-
mediately as the only chance for the patient, but considered that
almost desperate under the circumstances. We now gave her
tinct. opii gij., and waited half an hour, and then placed her upon
the table in proper position to operate. I commenced my in-
cision immediately above the base of the tumor and carried it
over it in the course of the femoral vein to a point about half an
inch below it, and down to the superficial fascia of the thigh,
which I pinched up and separated from the parts beneath by
rubbing it between my thumb and finger, and made a slight open-
ing into it and divided it upon the grooved director. I divided
each successive layer in the same way till I came down to the
sack, which was easily detected by the blue appearance and
elastic feel of the distended intestine within it. I now passed
my finger upon the outside of the sack and divided Gimbernat’s
ligament, when the stricture was immediately relieved, and the
gas passed out of the strangulated intestine. I now attempted
to return the sack and intestine entire, but found the sack adhe-
rent in every part so as to render that impossible. I then dis-
sected the sack loose with my fingers and the handle of the
scalpel, and attempted to return, but this I could not accomplish
in consequence of another stricture at the neck of the sack. I
now concluded to open the sack and divide the stricture at its
neck, but this I found very difficult to accomplish in consequence
of the intestine having contained nothing but gas, and this
having escaped as soon as the stricture upon the outside of the
sack was divided, and left it like a piece of wet bladder; but after
a good deal of trouble I succeeded in separating the sack from
the intestine, and puncturing it, then by seizing the whole and
drawing it down, I was enabled to pass the director and divide
the sack upon it. As soon as the sack was divided there was a
discharge of about one and a half ounces of clear serum. The
bowel appeared rather dark and congested, but otherwise healthy.
I returned the bowel first and then the sack, and closed the
wound by three stitches of the interrupted suture and straps of
adhesive plaster. The patient was very much exhausted, but
expressed herself entirely relieved. We now placed the patient
in bed upon her back, with the right thigh flexed upon the pelvis
in such a manner as to relax the abdominal muscles, and prevent
any pressure upon the wound by the contents of the abdomen,
and applied the simple warm water dressing. To have opium
one gr. every four hours, with light broth and wine whey for
nourishment. To be kept perfectly quiet and from changing
her position.
Jan. 17th, 10 A. M.—Patient passed a very good night, no
pain, very little thirst, gums less sore, tongue cleaning off, skin
warm and moist, pulse one hundred, full and soft, countenance
natural, less tympanites, and less soreness upon pressure. Passes
wind freely from the bowels, but no feculent matter. Continue
treatment as before.
Jan. 18th, 10 A. M.—Patient continues to improve ; relishes
nourishment, but still has passed no feculent matter. Continue
treatment, with the addition of an occasional injection of warm
water.
Jan. lDth, 10 A. M.—Patient continues to improve, wound
nearly united by the first intention. Bowels have been freely
moved by the injection; stool natural and consistent. From this
time forward my patient continued to improve rapidly, and in
about one month after she was operated upon she had entirely
recovered. I saw her three days since, and she is in robust
health, and the hernia seems to be radically cured, the cicatrix
being firmly united to the pubic bone. She experiences no in-
convenience from it whatever. The prominent points in this
case are: 1st. The complete relief of all the symptoms of stran-
gulation produced by calomel and opium and the soothing treat-
ment, although the stricture was not removed. 2d. The hope-
lessness of any attempt at reduction, by the taxis, of an old
hernia, although the patient may tell you, as mine did, that the
tumor only came down that morning, for I am satisfied, from the
amount of adhesions, that the hernia had been irreducible for
the last ten years. 3d. The injury that would result from per-
sisting in the taxis in such a case, the use of tart, ant., the to-
bacco injection, and the many other remedies that are recom-
mended in the books, in strangulated hernia. And lastly, the
complete success of an operation under circumstances apparently
so hopeless.
CASE II.—DISLOCATION OF THE FEMUR.
I was called to see Samuel B., November 22d, 1850, and
on enquiry I found that some two hours previous he had been
mining, upon his knees, wThen a fall of coal came down and struck
him upon the back part of the pelvis, in such a manner as to force
the head of the femur out of its socket and place it upon the
dorsum of the ilium, presenting outwards and backwards, with
the great trochanter resting against the edge of the acetabulum
behind, the limb being shortened near three inches, the foot in-
verted and resting upon the other above the instep. I had pur-
chased Dr. Jarvis’s instrument a few days previous, and I thought
this a very good opportunity for testing its good qualities; so I
placed my patient upon a common deal table, and applied the
instrument according to the Doctor’s directions; and now I sup-
posed that all I had to do was to turn the ratchet and the bone
would fly to its place; but after torturing my patient for some
two hours, trying my utmost to make the extension in the line
of displacement, I gave it up in despair, and adjourned the case
till nine o’clock the next day, very much cooled in regard to the
infallibility of the instrument I had purchased, at least in my
hands. But still supposing that my failure was more owing to
my inability to apply it than to any fault in the instrument, I
sent a note to Dr. Carpenter, (upon whose recommendation I had
been induced to purchase the instrument,) a gentleman of ac-
knowledged abilities in all cases of the kind, asking him to meet
me in consultation in the case. We met punctually to the time,
and I again applied the instrument, and asked him to take
charge of the limb and reduce it. He took charge of the limb,
and, laboring for near three hours, he gave it up in despair, also
perfectly satisfied that he could not make the extension in the
line of displacement, (the very thing for which the inventor re-
commends it so highly,) and that the lever placed upon the in-
strument would make a very nice plaything for a child, but
would certainly never subserve the purpose for which it was in-
tended, viz., forcing the head of the bone out of its malposition.
We now put the patient under the influence of chloroform, and
applied the sheets in the old way recommended in the books,
but soon found that we were unable to make extension suffi-
ciently long to overcome the resistance of the muscles ; conse-
quently we adjourned the case until 3 o’clock P. M., when we
again met and applied the compound pulley, and put the patient
under the influence of chloroform, when it was reduced in twenty
minutes. The patient was placed comfortably in bed, and at
the end of a week had so far recovered as to walk about with
ease. I would say in this connection to all medical students,
beware of all patented instruments for setting fractures and re-
ducing luxations, and in their place get a few good splints and
a set of compound pulleys, as they alone can be relied on in
practice, notwithstanding the many certificates they possess from
many of our professors who stand deservedly high in the pro-
fession.
CASE III.—DISLOCATION OF THE FEMUR.
I was called in consultation with a neighboring physician
to Dennis D., a young man about twenty-five years of age, a
miner by occupation. Some four hours previous, while en-
gaged in mining, upon his knees, a fall of coal came down, and a
large piece with a sharp cutting edge struck him immediately
over the os coccyx, cutting the soft parts down to the bone,
passing over the sphincter ani muscle, which receded before the
force of the blow and was uninjured ; it passed through the entire
length of the perineum and through the scrotum, separating the
testicles, leaving one upon either side of the incision. The
depth of the incision was about one inch. I cleaned out the
wound by removing the coal dirt and other foreign substances,
and closed it with the interrupted suture and adhesive straps,
and ordered the simple warm water dressing. Not supposing he
had received any other injury, as he made no other complaint,
I made no further examination, but left him in the hands of his
attending physician. On the 8th of January, 1852, just seven
weeks after he had been injured, I was again called to see him,
and was informed that he had not yet been able to leave his bed,
and that he had dismissed his physician because he was dissatis-
fied with his attendance. On examination, a dislocation of the
femur upwards and backwards into the sciatic notch was disco-
vered, which had occurred at the time of his injury. The wound
of the perineum was completely cicatrized, and I must confess
that I felt mortified that I had overlooked the dislocation at my
first visit, as I knew the attending physician, who was quite a
young man, depended upon me for a proper diagnosis in the
case, and as I had failed to detect it he had never suspected such
a thing. Seeing that the man must remain a cripple for life if
the dislocation remained unreduced, and that my reputation
must suffer as a necessary consequence, I determined, notwith-
standing the length of time it had remained in its malposition, to
attempt its reduction at all hazards.
On the 9th of January, in consultation with Dr. McKibbin,
we placed the patient on a bed upon the floor, and applied the
compound pulleys with the counter extending band upon the
injured side, and kept up extension for about 20 or 25 minutes
at a time, with intervals of rest for about two hours, without
being able to dislodge the head of the bone from the position it
had taken. We then shifted the counter extending band to the
sound side, and after keeping up extension constantly for about
half an hour, the head of the bone gradually slipped into its
place without the slightest noise. So gradual had been its re-
duction that we were not satisfied that it was reduced until, in
order to satisfy ourselves, we commenced flexing and extending
the limb when it slipped out again. We again applied the
pulleys and reduced it with a very slight effort; and again, in
trying to satisfy ourselves of its proper reduction, it slipped out,
but was again reduced with a very slight effort; when we placed
the patient upon his back in bed and bound his knees together
with a strong roller, and kept him in that position for four weeks,
when he was permitted to get up and go about on crutches. He
has at this date entirely recovered the use of his limb. The ace-
tabulum appeared to be almost entirely filled, hence the ease
with which it slipped out of its place after reduction. That the
head of the bone occupied the sciatic notch was clearly demon-
strated by an examination through the rectum, and by the canal
left in the fibres of the gluteic muscles after its reduction from
that point to the acetabulum, caused by its having traversed
from one point to the other.
x The prominent points in this case are : 1st. The necessity of
a thorough examination of every case to which we are called,
and the great injury that may result, not only to the patient,
but to our own reputation and to the profession at large, from its
neglect. 2d. That a dislocated femur may be reduced, nearly
two months after the accident, without injury to the patient; and
3d. The necessity of keeping up extension and counter-extension
continuously till the resistance of the muscles are overcome, or
while^the strength of the patient will permit, before giving up
our effort.