553

after the operation-i.e., after the removal of the adenoid,growths.

Remarks by Dr. SHAHnLOVP.-Dr. Eustace Smith pointed.out in two papers which appeared in THE LANCET ofMay 25th, 1895, and March 19th, 1898, that there is a closeRelationship between some cases of laryngeal stridor and.adenoid growths, so much so that if the vegetations beremoved the stridor disappears. In this connexion the- above case is very interesting and confirms the opinion’expressed in the papers mentioned. I am convinced thatrecovery in the present case was delayed by the meteoro-logical conditions which prevailed at the time, because-when the weather was damp the patient seemed to be.much worse and the nasal discharge was more profuse. The.effect of the removal of the adenoids in this case, I take it,was very striking. Not only did a laryngeal stridor whichhad been present since birth disappear in three weeks, butalso the child showed much more intelligence and improvedin every way. For permission to publish the notes of the<case I am indebted to Dr. Eustace Smith.

ROYAL SOUTHERN HOSPITAL, LIVERPOOL.A CASE OF ACUTE INTESTINAL OBSTRUCTION; LATENT

HERNIA ; LAPAROTOMY ; REDUCTION OF HERNIAFROM WITHIN ; DRAINAGE ; RECOVERY.

(Under the care of Dr. ALEXANDER.)IT can hardly be disputed that for strangulation of

1

inguinal or femoral hernia the ordinary external incision isthe best, as the hernia is situated comparatively super-

ficially and so no deep dissection is required, but in the caseof an obturator hernia the sac is so deeply placed that the- dissection needed to reach it is difficult, and therefore anabdominal section is preferable, especially when we con-,sider the slight local indications of the hernia. In cases of

inguinal or femoral hernia, if the local signs of a hernia arewanting, owing to the small amount of bowel involved, alaparotomy offers the best chance of success, as the cause ofthe obstruction of the bowel will then certainly be dis-covered, though the dangers of sepsis are undoubtedlyincreased. For the notes of the case we are indebted to.Mr. C. E. Morris, senior house surgeon.A boy, aged fifteen years, was admitted to the Royal

;Southern Hospital, Liverpool, on the afternoon of March 2nd,1898, giving the history that six days previously he had been,when dismounting from a pony, suddenly seized with verysevere pain in the right side of the abdomen. He vomited.and three loose stools containing a little blood were passed inxapid succession. From the onset of the attack up to the.admission of the patient to the hospital no stools or flatushad been passed. All nutriment taken had been vomited.’The pain had become less severe but was still greatest inthe right side of the abdomen. There had been no tenesmus.On admission the patient’s eyes were sunken and the featureswere drawn and pale. The legs were extended and theabdomen was found to be uniformly enlarged, firm, tym-panitic on percussion, and not moving with respiration, butit was not hyper&aelig;sthetic. No special tumour could befound. The temperature was 984&deg; F. and the pulse was 88.and small. It was decided to explore the abdominal

,cavity. Accordingly, a few hours later the patient wasprepared for operation and anaesthetised. On further carefulexamination it was thought that a very small indefinitetumour could be felt near the middle of the right Poupart’sligament. The abdominal cavity was opened by an incision.above, and nearly parallel to, the right Poupart’s ligament andwas found to contain much clear fluid ; the small intestineswere discoloured and distended. A little knuckle of bowel,just sufficient to occlude its own lumen, was found tightlygrasped by the right crural ring. This was cautiously and- easily withdrawn and as its condition, although very deeplycongested, did not suggest gangrene it was not further inter-fered with. When the hernia was being withdrawn a

,quantity of dark sanguineous fluid came away from the sacand was prevented by sponges from entering the abdominalcavity. The wound was closed, a glass drain carrying apiece of double cyanide gauze being inserted into theperitoneal cavity. On March 3rd the drain was removed.The pulse ranged from 100 to 120 and the temperature was98.4&deg;. On the 4th ten soft stools were passed. The patientmade a good recovery, with the exception that suppuration

occurred along the suture tracks, and on the twelfth dayafter the operation left orchitis developed, suppurated, wasincised and healed rapidly.Remarks by Mr. MORRIS -The points for consideration

suggested by the case are as follow: 1. The difficulty ofdiagnosing a small femoral hernia (almost a Littre’s hernia),especially when there is great distension of the abdomen.2. Rarity of femoral hernia in boys. 3. The occurrence ofleft orchitis after a wound of the right side of the abdomen.Was this caused by the end of the tube impinging upon theleft vas deferens or by sepsis travelling in an unusual path ? 24. The dangers of peritoneal infection from the hernial sacby the intra-abdominal method of operating are well shownin this case. Had the fluid in the sac been septic or thebowel sloughing it would have been very difficult with

sponges to prevent the possibility of peritoneal infection.Moreover, the sac would have had to be dealt with externallyafterwards.

Reviews and Notices of Books.Operative Gyn&aelig;cology. By HOWARD A. KELLY, A.B., M.D.

2 vols., 1100 p.p., with 24 Plates and 550 Illustrations.Royal 8vo. London : Henry Kimpton. 1898. ;f:3 3s. net.

THE announcement that Dr. Howard Kelly was writing awork upon operative gynaecology led us to anticipate its

appearance with great interest. The book, which is in twovolumes, has now been published and is undoubtedly themost important work upon this subject which has yet beenwritten in the English language. Not only the greatexcellence of the letterpress, but also the artistic merit ofthe very numerous illustrations with which it is furnished,renders the work one well worthy of the American school ofgynaecology and of the high reputation of its author.The first two chapters consist of a very full description of

the methods to be employed in attaining asepsis and anti-sepsis, both in hospital and in private practice. The

difficulties which beset the perfect sterilisation of catguthas led many surgeons to give up this most convenientform of ligature. From 1890 to 1894 in the Johns HopkinsHospital the catgut was prepared by soaking in ether andboiling in alcohol under pressure. At the beginning of 1894an outbreak of sepsis occurred, which was almost certainlytraced to the use of catgut prepared in this way. Since

1895 a modification of Kronig’s cumol method has beenemployed with success. This method consists of several

steps. First the catgut is heated in a sand bath at 80&deg; C. forone hour, it is then placed in cumol at 100&deg; C. and heated

up to 165&deg; C. (331&deg; F.), this temperature being maintainedfor an hour, and finally it is dried at 100&deg; C., for two hoursin a sand bath or a hot air oven, and thence transferredto sterilised glass tubes until used. The process issomewhat troublesome, but as it appears to be efficient

it should be of service to surgeons who wish to becertain of the asepsis of their catgut. Schatz’s methodof disinfecting the hands by immersing them in hot

saturated solutions of permanganate of potassium and

oxalic acid after a thorough preliminary scrubbing withhot water and soap is recommended, and the greatimportance of the preliminary washing for a definite

length of time is insisted upon. The chapter upon theTopographical Anatomy of the Pelvis is remarkable for thegreat beauty of the illustrations, especially those illustratingthe anatomy of the small intestine. The anatomy and actionof the levator ani muscle are well described. Under

Gynaecological Examinations the great value of photographyis pointed out and the chapter is illustrated by a numberof drawings obtained in this way of the various forms

assumed by the abdomen when distended by tumours or otherconditions. The examination of patients in the dorsal andother postures is fully described and the great value of rectal