ture began to rise, and the symptoms of peritonitis to subside ; but for the first four days, the patient Was troubled by constant hiccough. The operation wound healed partly by primary union, and partly by granulation. While the patient was in hospital, the rupture would come down on the slightest exertion on account of the large size of the- inguinal canal. The patient had been subject to the disease for many years, and used to wear a truss. He was discharged on the 27th March, 1875. Case II.?Pearynauth, a Hindu male, aged 26, was admitted with strangulated inguinal hernia of the left side. The rupture came down while the patient was singing loudly and this was soon followed by severe pain, which, commencing in the right inguinal region, gradually extended all over the abdomen. The patient being a villager, could not obtain anymedical aid until 6 days after the accident, when he wa3 brought to hospital. On admission, a hard, tense, and very painful tumour was found occupying the upper part of the scrotum, on right side. The tissues over the tumour were much braised and inflamed by persistent taxis which had been employed at home ; the patient was very low with symptoms of peritonitis well developed. As the tissues covering the sac of the hernia were subjected to much handling before admission, and were very painful, taxis was not tried, but a dose of liquor opii with application of ice over the tumour was resorted to, but without success. The patient was then put under chloroform, and the operation of herniotomy performed. The stricture which was situated outside the sac in the internal abdominal ring, was divided without opening the sac. The edges of the wound were then brought into apposition by a few stitches of iron wire, and covered with carbolic oil and lint over which a thin pad and a spica bandage were lightly applied. After the operation the symptoms of peritonitis instead of being relieved, gradually grew worse, and on the next morning the dressings over the wound were found stained with foecal matter, which was escaping into the peritoneal cavity from a rent in the reduced gut, and the patient sank on the same day, 16th July, hours 34 after the operation.
A MIRROR OF HOSPITAL PRACTICE. MAYO NATIVE HOSPITAL.
\
CASES OF STRANGULATED INGUINAL HERNIA TREATED DURING THE YEAR 1875. Under the
of Surgeon-Major H. Cayley. Reported Assistant Surgeon Piiositosth Haldaii.
care
by-
nurro Chundra, an old Hindu, aged 55, was admitqasE j the 19th February, 1875, with strangulated , int0 hospital on of the left side. The rupture came down eight scr0 til hernia admission, and was about the size of a child's head tended from the inguinal canal down to the upper which was filled by a large rt of the left tunica -vaginalis, On The tumour was tender and very painful. hydrocele His pulse was was in a very low state. admission the patient and weak. Temperature below normal; abdomen ,
'before
!d, small,and
tympanitic
painful;
bowels confined; vomiting frequent,
He was very restless with anxious but not stercoraceous. of ice over the tumour, and attempts countenance. Application been tried without success, the to reduce it by taxis having under choloroform, and after tapping natient was immediately put of herniotomy was performed. the hydrocele, the operation found necessary to open the sac, The rupture returned. It was adherent in several places by recent to which the bowel was to rally, adhesions. After the operation the patient began and stronger, his temperahis pulse gradually became fuller
Case III.?A Hindu male, aged 45. came to hospital on the 22nd July, with a strangulated scrotal hernia of the right side. The rupture descended 3 days before admission, was of large size, and very painful; the sac with the soft tissues over it, presented signs of mortification. The patient was very low. and symptoms of peritonitis were very marked. A dose of liquor opii was given immediately after admission and cold in the shape of ice applied over the hernia. As there was suspicion of gangrene in the descended gut, taxis was not resorted to, but the patient was put under chloroform, and the operation performed as usual. The sac was laid open in order to examine the condition of the parts within it. The protruded intestine was found highly congested, of a dark purple color, and distended with fluid faecal matter. It floated in a large quantity of decomposed serous fluid which escaped on opening the sac. The constricted point of the gut was found perforated, almost divided across, by sloughing; the bowel was adherent to the neck of the sac, and could not be returned. The intestine was punctured by a fine trocar and canula to let out its gaseous contents and left in the sac being covered with carbolic oil and lint. The patient died of exhaustion and peritonitis 23 hours after admission. Case IY.?Dinoo, a Hindu, aged 37, was admitted into Hoson the 17th August, with a strangulated scrotal rupture. The patient had been ruptured 10 years, and according to his statement, a portion of the intestine always remained down in the sac, but from time to time fresh portions of the gut would slip down which could be reduced without any difficulty. On admission into Hospital 12 hours after the strangulation, the tumour was found to be of large size, situate above the left testicle, but the local symptoms of strangulation were not The rupture was soft, and there was very little very urgent. pain and tenderness in it, but vomiting and other signs of peritonitis were very marked, and the patient was very low with feeble, small, and frequent pulse, cold extremities, great restlessness, and anxious countenance. After taxis, aided by cold applications over the tumour, had been tried without success, the patient was put under chloroform, and a second attempt made to reduce the hernia by manipulation, but with no better result. The operation of herniotomy was therefore performed, but as no stricture could be detected without the sac, the latter was laid open, a portion of the intes-
pital,
April 1,
A MIRROR OF HOSPITAL PRACTICE.
1876.]
tine returned into the abdomen, but the greater portion remained behind in the sac to which it was adherent by old adhesions. This portion of the gut was therefore left in the sac. The wound was then stitched up with sutures and dressed antisepticnlly. But signs of inflammation and sloughing appeared in the sue and adjacent soft structures. The symptoms of peritonitis became aggravated and the patient gradually sank 11? hours after the operation.
But on the 2nd day after operation the patient got an attack of bronchitis and during fits of coughing lost some blood from the wound. On the next two days there was also a little bleeding from the wound. On the 4th dny, the patient got inflammation of the whole scrotum and penis, attended with strong fever and delirium. The inflammation ended in sloughing of the scrotum which was freely incised to relieve its tension and prevent sloughing. The wound at the same time assumed an unhealthy appearance. Oa the 12th day, the itnflamation and sloughing began to subside and the fever ceased. The scrotum gradually attained its former size and the ulcers on it, caused by sloughing, healed. After this the patient made a rapid progress, without any untoward symptom supervening, and was discharged cured on the loth March 1875. Tiie hernia never came down as long as the patient was in
CaseV.?Dhuntur, a Mahomadan aged 40, was admitted on the 16th June, with strangulated inguinal hernia of the right side. He had been ruptured ia his childhood, but never had strangulation before. On admission, 6 hours after the strangu lation occurred, a tumour about the size of a closed fist, was observed below the right inguinal canal extending down to ttie upper part of the right tunica vaginalis; it was hard, elastic, and tender, to the touch. The abdotnen was tympanitic and tender, vomiting now and then, bowels costive ; pulse rather weak ; temperature normal; thirst and great restlessness. An opiate, with ice over the tumour was ordered immediately after admission, but these had no effect. Taxis was then tried under chloroform, but without success. The operation of herniotomy was therefore performed, and after division of the structure, which was situate at the external ring, it was found necessary to open the sac. The bowels was then returned with some effort. The hernia was a congenital one and occupied the cavity of the right tunica vaginalis, from which the testis was absent. The gut though congested, was returned, but no unfavorable symptoms subsequently followed. '] he wound was stitched up and dressed antiseptically and healed within a few days after the operation. The peritonitis also gradually subsided, the b iwels were moved, and the patient soon rallied But a few days after the operation the right side of the scrotum got inflamed, and there was suppuration withm the right tunica vaginalis, which was freely laid open. The discharge continued for a few days and then ceased The patient was discharged cured on the 22nd July, 187o. During the stay of tfle patient in hospital, the hernia never came down. -
Hospital.
In the above 7 cases, there were 4 deaths and 3 recoveries, this is a very high rate of mortality ; but in the fatal cases the result was due rather to the almost hopeless condition at the time of operation than to the effects of the operation itself. Tne operation of herniotomy, when performed early, is very successWhen performed after inflammation has set in, the results ful. are most unfavorable; but at tne same time of course it affords the onlr possible chance of relief. In the following cases the hernia was reduced by means of cold
application
and taxis?without any
operation
:
Hindu male, aged 45, ruptured 12 years, a admitted with inguinal hernia of the rigtit side, of one hour's duration. There was no symptom of strangulation and the hernia was reduced by taxis immediately after admission.
Cask!?Jodu,
was
Oasf, 11.?Lukhee, a Hindu male, aaed 40, ruptured 6 months, admitted on the 31st March with strangulated inguinal hernia of 4? hours' duration. The constitutional symptoms were not well marked, and except a little tenderness in the tumor and abdomen the local signs of strangulation were not prominent. The patient vomited once before admission ; his bowels were confined. The hernia was easily reduced by tasis immediately after admission. A dose of liquor opii was given after reduction of the hernia, and the patient soon got well, and was discharged on the 3rd day. was
Case VI.?Ramdhun, a Hindu male, aged 45, came in on 2nd December with strangulated inguinal hernia of the right side of 11 hours' duration. The tumonr was hard, tense and painful, and occupied tile upper part of the right testicle. On admission he was very low, and the pulse was scarcely perceptible ; abdoand tender to the touch; bowels conmen highly tympanitic fined, and vomiting frequent. Taxis and cold application ever was first resorted tumour the to, but without success. The patient was therefore put under chloroform and the operation After dividing the stricture and of herniotomy performed layin" open the sac, the gut was returned into the abdomen ; but sunk from exhaustion and peritonitis on the
Case III.?Buruoktoolah, a Mahomedan youth, aged 19 years, one year, had strangulated inguinal hernia of left side The patient was sent from Ohandnie, but cf 3 hours' duration A dose of opiate was on his way the hernia 'went up of itself. a pad and spica bundage applied. and He given on admission was discharged on the next day, 17th April.
ruptured
patient gradually
the 4th December, 1875. was Hindu male, aged 30, Case VII ?Bydonnuth, admitted with strangulated inguinal hernia of the light side. The rupture came down while the patient was struggling with aitother. On admission, 31 hours after strangulation, ttie tumour was found to be of small size and soft, without much pain, tenderness, or any other sign of inflammation. It extended from the lower part of the external abdominal ring to the upper part of the scrotum. Symptoms of peritonitis had already commenced; the abdomen was tympanitic, tender and a little painful; bowels confined ; vomiting constant; had three scanty stools after admission. Although the local signs were not very marked, the constitutional symptoms were well developed, the patient was very low with scarcely perceptable pulse; temperature below normal; great restlessness; thirst and constant retching; countenance pinched and anxious; and body covered with cold clammy perspiration. Application of ice and attempt at reduction by manipulation having failed, the patient was put under chloroform and the operation of herniotomy performed. After division of the stricture, which was situated at the external ring without the sac, the gut was easily put back without opening the sac ; the patient lost very little blood and no ligature was required to stop the bleeding. The wound was stitched with iron wire sutures and then dressed antiseptically. Soon after the operation the patient's general condition was fuller and stronger, tembecame His greatly improved. pulse perature rose to the normal standard. Vomiting ceased, bowels were freely moved, and the patient felt great relief. The symptoms of peritonitis gradually subsided.
101
?
j
Case IV ?Beharumjee (an inhabitant of Bombay) a Parsee, 40 years of age was admitted on the 15th May, with inguinal On admission, 26 hours after the hernia of the right side. descent of the hernia, the tumour was found to be about, the size of a child's head. The signs of strangulation were not very acute there being only a little tenderness in the tumour and abdoThe hernia was reduced men, with no constitutional symptoms. by the application of ice and munipulation. After the reduction, the patient complained of a little pain in the abdomen which was relieved by a full dose of opiate. The patient was discharged on the next day. Cask Y.? Sreenauth, a Hindu male, aged 60 years, was admitted on the 16th June, with strangulated inguinal hernia of 8 hours' duration. The hernia was reduced by manipulation. He had been ruptured 16 years, but had never had strangulation before. After reduction a full dose of an opiate was given to relieve the pain in his abdomen. The patient was discharged on the next day. Case VI.?Shaik Nathoo, a Mahomedan male, aged 55, was admitted on the 12th October with strangulated inguinal hernia of the right side. On admission 8 hours after the descent of the hernia, a big tumour was found occupying the upper part of the scrotum behind the right testicle. The tumour, was tender and painful, but not very hard or tense.
There was pain and tenderness in the abdomen which was a little tense and tympanitic: The patient vomited several times pulse weak and small; temperature normal.
?
102
THE INDIAN MEDICAL GAZETTE.
Taxis was tried at the Chandnie Hospital, but without success. After admission a full dose of liquor opii was given and cold applied over the tumour. The patient was then put under chloroform, and the hernia reduced by manipulation. On the next day the patient had a free stool, but still complained of pain in the abdomen. The pain continued for several days and then ceased. He was discharged on the 1st November, 1875. Cask YII.?Ajodhyaprosad, a Hindustani, aged 50 years, was admitted on the 19th October, with strangulated inguinal hernia of the right side of 3 days' duration. On admission he complained of much pain and tenderness in the hernia and abdomen. Vomited several times and was troubled with constant hiccough ; bowels confined ; pulse weak and frequent; temperature normal. A dose of liquor opii and cold application over the tumour were tried immediately after admission, and the intestine went up af:er a few minutes. After the operation the hiccough and constipation still continued. The constipation was relieved by a dose of oil and bismuth, with chloric ether, and hydrocyanic acid was given to stop the hiccough, which, however, continued for four days and then ceased. The patient was discharged on the 24th October, 1875.
[April 1,
1876.
A MIRROR OF HOSPITAL PRACTICE. MAYO NATIVE HOSPITAL.
\
CASES OF STRANGULATED INGUINAL HERNIA TREATED DURING THE YEAR 1875. Under the
of Surgeon-Major H. Cayley. Reported Assistant Surgeon Piiositosth Haldaii.
care
by-
nurro Chundra, an old Hindu, aged 55, was admitqasE j the 19th February, 1875, with strangulated , int0 hospital on of the left side. The rupture came down eight scr0 til hernia admission, and was about the size of a child's head tended from the inguinal canal down to the upper which was filled by a large rt of the left tunica -vaginalis, On The tumour was tender and very painful. hydrocele His pulse was was in a very low state. admission the patient and weak. Temperature below normal; abdomen ,
'before
!d, small,and
tympanitic
painful;
bowels confined; vomiting frequent,
He was very restless with anxious but not stercoraceous. of ice over the tumour, and attempts countenance. Application been tried without success, the to reduce it by taxis having under choloroform, and after tapping natient was immediately put of herniotomy was performed. the hydrocele, the operation found necessary to open the sac, The rupture returned. It was adherent in several places by recent to which the bowel was to rally, adhesions. After the operation the patient began and stronger, his temperahis pulse gradually became fuller
Case III.?A Hindu male, aged 45. came to hospital on the 22nd July, with a strangulated scrotal hernia of the right side. The rupture descended 3 days before admission, was of large size, and very painful; the sac with the soft tissues over it, presented signs of mortification. The patient was very low. and symptoms of peritonitis were very marked. A dose of liquor opii was given immediately after admission and cold in the shape of ice applied over the hernia. As there was suspicion of gangrene in the descended gut, taxis was not resorted to, but the patient was put under chloroform, and the operation performed as usual. The sac was laid open in order to examine the condition of the parts within it. The protruded intestine was found highly congested, of a dark purple color, and distended with fluid faecal matter. It floated in a large quantity of decomposed serous fluid which escaped on opening the sac. The constricted point of the gut was found perforated, almost divided across, by sloughing; the bowel was adherent to the neck of the sac, and could not be returned. The intestine was punctured by a fine trocar and canula to let out its gaseous contents and left in the sac being covered with carbolic oil and lint. The patient died of exhaustion and peritonitis 23 hours after admission. Case IY.?Dinoo, a Hindu, aged 37, was admitted into Hoson the 17th August, with a strangulated scrotal rupture. The patient had been ruptured 10 years, and according to his statement, a portion of the intestine always remained down in the sac, but from time to time fresh portions of the gut would slip down which could be reduced without any difficulty. On admission into Hospital 12 hours after the strangulation, the tumour was found to be of large size, situate above the left testicle, but the local symptoms of strangulation were not The rupture was soft, and there was very little very urgent. pain and tenderness in it, but vomiting and other signs of peritonitis were very marked, and the patient was very low with feeble, small, and frequent pulse, cold extremities, great restlessness, and anxious countenance. After taxis, aided by cold applications over the tumour, had been tried without success, the patient was put under chloroform, and a second attempt made to reduce the hernia by manipulation, but with no better result. The operation of herniotomy was therefore performed, but as no stricture could be detected without the sac, the latter was laid open, a portion of the intes-
pital,
April 1,
A MIRROR OF HOSPITAL PRACTICE.
1876.]
tine returned into the abdomen, but the greater portion remained behind in the sac to which it was adherent by old adhesions. This portion of the gut was therefore left in the sac. The wound was then stitched up with sutures and dressed antisepticnlly. But signs of inflammation and sloughing appeared in the sue and adjacent soft structures. The symptoms of peritonitis became aggravated and the patient gradually sank 11? hours after the operation.
But on the 2nd day after operation the patient got an attack of bronchitis and during fits of coughing lost some blood from the wound. On the next two days there was also a little bleeding from the wound. On the 4th dny, the patient got inflammation of the whole scrotum and penis, attended with strong fever and delirium. The inflammation ended in sloughing of the scrotum which was freely incised to relieve its tension and prevent sloughing. The wound at the same time assumed an unhealthy appearance. Oa the 12th day, the itnflamation and sloughing began to subside and the fever ceased. The scrotum gradually attained its former size and the ulcers on it, caused by sloughing, healed. After this the patient made a rapid progress, without any untoward symptom supervening, and was discharged cured on the loth March 1875. Tiie hernia never came down as long as the patient was in
CaseV.?Dhuntur, a Mahomadan aged 40, was admitted on the 16th June, with strangulated inguinal hernia of the right side. He had been ruptured ia his childhood, but never had strangulation before. On admission, 6 hours after the strangu lation occurred, a tumour about the size of a closed fist, was observed below the right inguinal canal extending down to ttie upper part of the right tunica vaginalis; it was hard, elastic, and tender, to the touch. The abdotnen was tympanitic and tender, vomiting now and then, bowels costive ; pulse rather weak ; temperature normal; thirst and great restlessness. An opiate, with ice over the tumour was ordered immediately after admission, but these had no effect. Taxis was then tried under chloroform, but without success. The operation of herniotomy was therefore performed, and after division of the structure, which was situate at the external ring, it was found necessary to open the sac. The bowels was then returned with some effort. The hernia was a congenital one and occupied the cavity of the right tunica vaginalis, from which the testis was absent. The gut though congested, was returned, but no unfavorable symptoms subsequently followed. '] he wound was stitched up and dressed antiseptically and healed within a few days after the operation. The peritonitis also gradually subsided, the b iwels were moved, and the patient soon rallied But a few days after the operation the right side of the scrotum got inflamed, and there was suppuration withm the right tunica vaginalis, which was freely laid open. The discharge continued for a few days and then ceased The patient was discharged cured on the 22nd July, 187o. During the stay of tfle patient in hospital, the hernia never came down. -
Hospital.
In the above 7 cases, there were 4 deaths and 3 recoveries, this is a very high rate of mortality ; but in the fatal cases the result was due rather to the almost hopeless condition at the time of operation than to the effects of the operation itself. Tne operation of herniotomy, when performed early, is very successWhen performed after inflammation has set in, the results ful. are most unfavorable; but at tne same time of course it affords the onlr possible chance of relief. In the following cases the hernia was reduced by means of cold
application
and taxis?without any
operation
:
Hindu male, aged 45, ruptured 12 years, a admitted with inguinal hernia of the rigtit side, of one hour's duration. There was no symptom of strangulation and the hernia was reduced by taxis immediately after admission.
Cask!?Jodu,
was
Oasf, 11.?Lukhee, a Hindu male, aaed 40, ruptured 6 months, admitted on the 31st March with strangulated inguinal hernia of 4? hours' duration. The constitutional symptoms were not well marked, and except a little tenderness in the tumor and abdomen the local signs of strangulation were not prominent. The patient vomited once before admission ; his bowels were confined. The hernia was easily reduced by tasis immediately after admission. A dose of liquor opii was given after reduction of the hernia, and the patient soon got well, and was discharged on the 3rd day. was
Case VI.?Ramdhun, a Hindu male, aged 45, came in on 2nd December with strangulated inguinal hernia of the right side of 11 hours' duration. The tumonr was hard, tense and painful, and occupied tile upper part of the right testicle. On admission he was very low, and the pulse was scarcely perceptible ; abdoand tender to the touch; bowels conmen highly tympanitic fined, and vomiting frequent. Taxis and cold application ever was first resorted tumour the to, but without success. The patient was therefore put under chloroform and the operation After dividing the stricture and of herniotomy performed layin" open the sac, the gut was returned into the abdomen ; but sunk from exhaustion and peritonitis on the
Case III.?Buruoktoolah, a Mahomedan youth, aged 19 years, one year, had strangulated inguinal hernia of left side The patient was sent from Ohandnie, but cf 3 hours' duration A dose of opiate was on his way the hernia 'went up of itself. a pad and spica bundage applied. and He given on admission was discharged on the next day, 17th April.
ruptured
patient gradually
the 4th December, 1875. was Hindu male, aged 30, Case VII ?Bydonnuth, admitted with strangulated inguinal hernia of the light side. The rupture came down while the patient was struggling with aitother. On admission, 31 hours after strangulation, ttie tumour was found to be of small size and soft, without much pain, tenderness, or any other sign of inflammation. It extended from the lower part of the external abdominal ring to the upper part of the scrotum. Symptoms of peritonitis had already commenced; the abdomen was tympanitic, tender and a little painful; bowels confined ; vomiting constant; had three scanty stools after admission. Although the local signs were not very marked, the constitutional symptoms were well developed, the patient was very low with scarcely perceptable pulse; temperature below normal; great restlessness; thirst and constant retching; countenance pinched and anxious; and body covered with cold clammy perspiration. Application of ice and attempt at reduction by manipulation having failed, the patient was put under chloroform and the operation of herniotomy performed. After division of the stricture, which was situated at the external ring without the sac, the gut was easily put back without opening the sac ; the patient lost very little blood and no ligature was required to stop the bleeding. The wound was stitched with iron wire sutures and then dressed antiseptically. Soon after the operation the patient's general condition was fuller and stronger, tembecame His greatly improved. pulse perature rose to the normal standard. Vomiting ceased, bowels were freely moved, and the patient felt great relief. The symptoms of peritonitis gradually subsided.
101
?
j
Case IV ?Beharumjee (an inhabitant of Bombay) a Parsee, 40 years of age was admitted on the 15th May, with inguinal On admission, 26 hours after the hernia of the right side. descent of the hernia, the tumour was found to be about, the size of a child's head. The signs of strangulation were not very acute there being only a little tenderness in the tumour and abdoThe hernia was reduced men, with no constitutional symptoms. by the application of ice and munipulation. After the reduction, the patient complained of a little pain in the abdomen which was relieved by a full dose of opiate. The patient was discharged on the next day. Cask Y.? Sreenauth, a Hindu male, aged 60 years, was admitted on the 16th June, with strangulated inguinal hernia of 8 hours' duration. The hernia was reduced by manipulation. He had been ruptured 16 years, but had never had strangulation before. After reduction a full dose of an opiate was given to relieve the pain in his abdomen. The patient was discharged on the next day. Case VI.?Shaik Nathoo, a Mahomedan male, aged 55, was admitted on the 12th October with strangulated inguinal hernia of the right side. On admission 8 hours after the descent of the hernia, a big tumour was found occupying the upper part of the scrotum behind the right testicle. The tumour, was tender and painful, but not very hard or tense.
There was pain and tenderness in the abdomen which was a little tense and tympanitic: The patient vomited several times pulse weak and small; temperature normal.
?
102
THE INDIAN MEDICAL GAZETTE.
Taxis was tried at the Chandnie Hospital, but without success. After admission a full dose of liquor opii was given and cold applied over the tumour. The patient was then put under chloroform, and the hernia reduced by manipulation. On the next day the patient had a free stool, but still complained of pain in the abdomen. The pain continued for several days and then ceased. He was discharged on the 1st November, 1875. Cask YII.?Ajodhyaprosad, a Hindustani, aged 50 years, was admitted on the 19th October, with strangulated inguinal hernia of the right side of 3 days' duration. On admission he complained of much pain and tenderness in the hernia and abdomen. Vomited several times and was troubled with constant hiccough ; bowels confined ; pulse weak and frequent; temperature normal. A dose of liquor opii and cold application over the tumour were tried immediately after admission, and the intestine went up af:er a few minutes. After the operation the hiccough and constipation still continued. The constipation was relieved by a dose of oil and bismuth, with chloric ether, and hydrocyanic acid was given to stop the hiccough, which, however, continued for four days and then ceased. The patient was discharged on the 24th October, 1875.
[April 1,
1876.
