A CASE OP
By
W. E.
STRANGULATED DIRECT
INGUINAL
HERNIA. Civil Surgeon of Chittagong. Allen, F.R.C.S., Offg. oil to fir
July 4th, 1862.?I
was asked to see, in consultation, a young who had been admitted into hospital the evening before with a swelling in the right groin, and symptoms of strangulated hernia. He states that the tumour made its On exappearance suddenly during the act of defecation. amination, a swelling, tense and incompressible, was found extending from a little outside the centre of Potipart's ligament to the bottom of the scrotum ; a finger could be pushed uuder the outer extremity of the swelling opposite the centre of Poupart's ligament or the situation of the external abdominal ring, thus showing that the neck of the rupture was internal to that opening : no impulse on coughing or gurgling of flatus could be detected in the swelling; the existence of fluid at the lower part of the swelling probably in the tunica vaginalis was made out, and six or seven ounces of blood tinged serum had previously been drawn off. The taxis and enemata had been used without effect. The patient was put under the influence of chloroform, and the taxis again perseveringly used without avail ; as however there was not. any vomiting or acceleration of pulse or other sign of constitutional disturbance, it was decided to defer the operation a few more hours ; copious enemuta were administered which were returned after a few minutes without any admixture with fcecal matter. At 6 p.m., about 24 hours after the occurrence of the rupture, no change had been effected ; the patient complained of great tormina, vomiting had supervened, and there was some tenderness over the neck of the tumour ; it was decided that the operation could not be longer deferred. Chloroform having been administered, a last (unsuccessful) attempt was made by the taxis to return the gut. An incision about three inches long was then made over the neck of the swelling, three or four subjacent layers of tissue were carefully dissected and divided to the same extent, thus exposing the sac, through which the dull red colour of the gut could be discerned; a finger was passed round the neck of the sac, and a tight tendinous band on the inner side divided, after which, however, the gut could not be returned; the sac was then opened and found to contain a knuckle of inflated intestine, of the colour of liver, the serous covering of the gut retained its gloss ; there were also about two drachms of serous fluid contained in the sac. On passing the finper into the neck of the sac, the constriction appeared to be produced by the lower arched marpin of the internal oblique and transverse muscles : the constricting part was divided upward and inward to the extent of about i of an inch, and the gut easily returned into the belly. Three sutures and a compress were applied, and the patient removed to bed. To have calomel and opium every three hours. He made uninterrupted progress to complete recovery, and forty days after the operation the wound was entirely healed, and he went on two months' leave to his home. The above seems to be a typical case of direct hernia; the fact of its having occurred, as is usual, suddenly, during a violent muscular effort, that the upper or outer extremity of the swelling did not subside gradually as in oblique hernia, but was somewhat blunted, and allowed a finger to be pushed underneath it, were circumstances pathognomonic of that accident. The co-existence of hydrocele for a moment obscured the diagnosis. The existence of this complication, by no means uncommon in old cases of rupture, is worthy of remark, as showing with what rapidity an effusion of 6 or 7 ounces of fluid into the tunica vaginalis may take place. It is scarcely necessary to make the practical remark that the sooner after strangulation is made out the operation is performed, the greater the chance of recovery, or that the surgeon will rarely if ever meet with all the layers enumerated by the anatomist?a matter, however, which is of small importance, provided he operates cautiously, and can recognize the sac when he has reached it.
nian
(native)
By
W. E.
STRANGULATED DIRECT
INGUINAL
HERNIA. Civil Surgeon of Chittagong. Allen, F.R.C.S., Offg. oil to fir
July 4th, 1862.?I
was asked to see, in consultation, a young who had been admitted into hospital the evening before with a swelling in the right groin, and symptoms of strangulated hernia. He states that the tumour made its On exappearance suddenly during the act of defecation. amination, a swelling, tense and incompressible, was found extending from a little outside the centre of Potipart's ligament to the bottom of the scrotum ; a finger could be pushed uuder the outer extremity of the swelling opposite the centre of Poupart's ligament or the situation of the external abdominal ring, thus showing that the neck of the rupture was internal to that opening : no impulse on coughing or gurgling of flatus could be detected in the swelling; the existence of fluid at the lower part of the swelling probably in the tunica vaginalis was made out, and six or seven ounces of blood tinged serum had previously been drawn off. The taxis and enemata had been used without effect. The patient was put under the influence of chloroform, and the taxis again perseveringly used without avail ; as however there was not. any vomiting or acceleration of pulse or other sign of constitutional disturbance, it was decided to defer the operation a few more hours ; copious enemuta were administered which were returned after a few minutes without any admixture with fcecal matter. At 6 p.m., about 24 hours after the occurrence of the rupture, no change had been effected ; the patient complained of great tormina, vomiting had supervened, and there was some tenderness over the neck of the tumour ; it was decided that the operation could not be longer deferred. Chloroform having been administered, a last (unsuccessful) attempt was made by the taxis to return the gut. An incision about three inches long was then made over the neck of the swelling, three or four subjacent layers of tissue were carefully dissected and divided to the same extent, thus exposing the sac, through which the dull red colour of the gut could be discerned; a finger was passed round the neck of the sac, and a tight tendinous band on the inner side divided, after which, however, the gut could not be returned; the sac was then opened and found to contain a knuckle of inflated intestine, of the colour of liver, the serous covering of the gut retained its gloss ; there were also about two drachms of serous fluid contained in the sac. On passing the finper into the neck of the sac, the constriction appeared to be produced by the lower arched marpin of the internal oblique and transverse muscles : the constricting part was divided upward and inward to the extent of about i of an inch, and the gut easily returned into the belly. Three sutures and a compress were applied, and the patient removed to bed. To have calomel and opium every three hours. He made uninterrupted progress to complete recovery, and forty days after the operation the wound was entirely healed, and he went on two months' leave to his home. The above seems to be a typical case of direct hernia; the fact of its having occurred, as is usual, suddenly, during a violent muscular effort, that the upper or outer extremity of the swelling did not subside gradually as in oblique hernia, but was somewhat blunted, and allowed a finger to be pushed underneath it, were circumstances pathognomonic of that accident. The co-existence of hydrocele for a moment obscured the diagnosis. The existence of this complication, by no means uncommon in old cases of rupture, is worthy of remark, as showing with what rapidity an effusion of 6 or 7 ounces of fluid into the tunica vaginalis may take place. It is scarcely necessary to make the practical remark that the sooner after strangulation is made out the operation is performed, the greater the chance of recovery, or that the surgeon will rarely if ever meet with all the layers enumerated by the anatomist?a matter, however, which is of small importance, provided he operates cautiously, and can recognize the sac when he has reached it.
nian
(native)
