Elizabeth Stuckey, aet 57, an unmarried woman, and who has never given birth to a child, has been the subject of femoral hernia, on the left side, for the last twenty-five years.  She attributes the formation of the tumour to a severe attack of bilious vomiting, from which she suffered extremely, about the period of the cessation of the catamenia.

Contemporaneously with the hernia, she was attacked with pain and weakness in the back, which finally issued in curvature of the spinal column; the spine being now extremely distorted, and the left shoulder very much projected. To obtain relief from the excruciating pains in the back, she very soon had recourse to opium, which she now lakes in large quantities, frequently to the extent of a drachm, in the course of the day.

In addition to the foregoing affections, during the last twelve or eighteen months, the left mamma has become scirrhous, and recently ulcerated.

Such were the diseases of the poor creature, to whom I was called, on Wednesday evening, the 28th ult. [October 1840]. Extreme curvature of the spine, carcinomatous ulcer of the breast, the habitual practice of opium-eating, and an incarcerated hernia. On inquiry, I ascertained that the intestine had descended on Tuesday evening, and baffled all her attempts at reduction during the night. In the early part of Wednesday a surgeon was sent for, who applied the taxis, but without effect; there were no symptoms whatever of strangulation present, no sickness, no pain, no anxiety, no tension of the belly. On examination I found femoral hernia, rather larger than a goose egg, very hard, and manifestly filled with indurated faeces; but not at all tender to the touch, nor were the integuments swollen or inflamed. I bled her to incipient syncope, and attempted the reduction of the tumour by the taxis, but without success; emetic tartar was administered, and nausea established, but to equally little purpose. As, however, no symptom of strangulation was present, I did not feel justified in cutting down on the intestine, but left her for the night, determining to try the effect of a tepid bath (which could not then be procured), on the following morning. 

Thursday, 10 A.M.—She was placed in the warm bath till faintness and relaxation were produced, and the taxis again instituted, but without effect. Ordered to take a pill, composed of calomel, two grains, and compound extract of colocynth, eight grains, every two hours, and to have an enema with castor-oil. 

8 P.M.—The enema has returned without the slightest discolouration, and the stomach rejected the medicines. No alvine evacuation since Tuesday morning. The tumour is more painful, and somewhat inflamed; the belly is also swelled, and the pulse quick; countenance extremely anxious, and very pale. There has also been vomiting. I now proposed the operation, to which the patient consented; but my seniors in the profession thought it had better be postponed till the morning, as there was no urgent symptom present.

Friday, 10 A.M. —Evidently much worse; slight hiccough has intervened, and all the other symptoms become aggravated; the operation was now decided on, which I performed in the usual manner, by the inverted T incision. On opening the sac the intestine was found much inflamed and thickened, but only slightly congested, and the investing peritoneum was so completely softened by the inflammatory process as to peel off under the finger.* In returning the gut I experienced considerable difficulty from its size, and the solidity of its contents, and was compelled to divide Poupart's ligament pretty freely, upwards and inwards. There was no omentum in the sac. She bore the operation well, and the pulse was good. 

5 P.M.—There have been five alvine evacuations since the operation, without assistance from medicine. The faeces are of dark colour, and very hard; pulse 91, soft and compressible. 

11 P.M.—Two more dejections. Has been perfectly free from pain since the operation;  pulse 80. To take forty minims of the liquor opii sedativos. 

Sunday, 11 A.M.—Passed a quiet and tranquil night; but sleep has been prevented by the constant evacuation of the bowels, there having been upwards of twelve motions during the night. Thinking this diarrhoea to proceed from inflammation of the mucous membrane of the intestine, I ordered twelve leeches immediately to the abdomen. 

10 P.M.—Not so well skin hot and dry:  tongue furred; pulse hard, 85; belly tense.  Bled to fourteen ounces, and a gruel enema to be exhibited. 

Sunday, 11 A.M.—One healthy pultaceous stool in the night; countenance cheerful; skin moist; tongue becoming clean; belly flaccid and free from pain, and not tender on pressure; pulse 90, soft. She expressed herself as comfortable and much relieved by the bleeding of the preceding evening. Dressed the wound, in which adhesion had occurred throughout. 

Tuesday.—Very weak, in all other respects doing well. Ordered a little meat, and a few ounces of malt liquor. From this period the recovery was rapid and permanent. 

Throughout the case I was much struck with the tardy progress of the symptoms, and with the absence of that violence, which is so apt to characterise them in femoral hernia; and this is the more remarkable, when we take into consideration the bad state of the patient’s constitution, and the complication of diseases under which, she laboured previously to this attack. 

The tobacco enema, at all times a very  questionable remedy, but more especially in cases of femoral hernia, was not here used; and the administration of it is, I believe, more frequently attended with the most dangerous (sometimes fatal) effects, than with any real advantage. It will be noticed, that during the twenty hours which immediately succeeded the operation, the bowels were moved nineteen times; in short, a complete state of diarrhoea established, though no aperient medicines had been administered. This fact, I think, manifestly points out the malpraxis of giving strong purgatives immediately after the operation; or, in other words, adding a fresh source of irritation to an already highly-irritated and inflamed membrane.

I will no farther trespass on your valuable pages, than by thus publicly expressing my grateful sense of the kind assistance of Messrs. Holman and Hainworth during the operation. 

 

* Query. Effused lymph.—Ed. L.