SEHORE DISPENSARY. RADICAL CURE OF
A CASE OF DIRECT INGUINAL HERNIA. By Surgeon-Major F. Odevaine, F.K..C.S.
The
a well-developed, tall, muscular man, aged about native of Jeddali, was admitted into the Sehore Dispensary for sinus of the right side of the chest, extendiug between the pectoral muscles. He had also a right direct inguinal hernia, which came down only when he waited, and which, though not very large, yet gave him a good deal of annoyance, so much so, that be expressed a strong wish to be permanently cured of it. He stated the hernia first appeared three years ago. On reducing the protrusion, and forcibly pushing the index finger upwards and backwards through the external abdominal ring, its point becomes engaged in an opening in the conjoined tendons, immediately to the outer margin of the right rectus, or, more correctly speaking, the pyramidalis muscle, when it is present; the base of the opening is formed by a part of the transverse ramus of the pubes, and the sides somewhat lunated meet above in the form of an arch. If the patient is desired to cough strongly, the hernia is felt to impinge on the point of the finger, occupying the opening alluded to. Some days after the patient's admission into the dispensary, having given him a suitable aperient, the pube3 was shaved I took and he was placed on his back on the operating table. a slightly curved long needle, the eye near its point, and fixed in a strong handle, the convexity of the needle I placed on the palmar aspect of my right index finger, the handle of the instrument being firmly fixed by the thumb and other fingers of the same hand. I then pushed the centre of the scrotum of the right side upwards until the finger and needle were engaged in the hernial opening, when the inner tendinous margin of this was transfixed, the point of the needle being directed upwards, fowards and a little outwards, and made to protrude through the integument at about two inches above the aperture in the conjoined tendons. A strong piece of pure silver wire which was then was passed through the eye of the needle, partly withdrawn, but not wholly removed from the point of entrance in the scrotum : the direction of the needle was next changed in such a way that it, with the engaged loop of wire, made a sweep outwards, and then its point guided by the forefinger was made to perforate the external pillar of the hernial opening from within outwards, and, by having the skin of the abdomen drawn in an external direction, the needle made its exit through the first aperture in front; the wire having been removed from the needle, the latter -was withdrawn. There were thus four strands of silver wire left protruding through the anterior puncture, their ends were firmly twisted, the right thigh being flexed and bent inwards, so as to relax the abdominal walls and allow of the approximation of the sides of the opening in the conjoined tendons, the twisted ends were cut close off and the skin pulled upwards, which allowed the wire to disappear in a direction towards the pubes. A spica bondage was applied and the patient directed to remain in bed. After the operation it was found that the centre of the scrotum on the right side still remained invaginated, probably owing to the needle in its sweep outwards, and before transfixing the external pillar of the hernial opening, having caught some fascia of this part and : ept it tucked up. This had, however, disits normal appeared by the next day, and the scrotum resumed allowed to walk position. Some days after, the patient was about, the bandage beingkept applied, and he complained of not the 1 a9t pain in the part, except when firm pressure was made over the vicinity of the external abdominal ring, in which situation the wire could be indistinctly felt. On the fourteenth day after the operation the bandage was removed, and the man permitted to move about, and no further protrusion of the but unfortunataly I waa prevented from took
30, and
patient,
rupture
a
place,
1
/
THE INDIAN MEDICAL GAZETTE.
156
testing the effect of much walking or violent exercise, 33 the patient without any apparent reason absconded. The above operation for the radic.il cure of hernia was first described and put into practice by Dr. J. J. Chisolm of the South Carolina Medical College as far back as 1859, and has the advantage of being simple, and, with care, free from danger. In cases in which the opening in the abdominal walls is very large, I should think it unBiiited, as its success depends greatly of the scrotum partly filling upon the invaginnted structures which the hernia protruded, and, ot' up the aperture through of structure thus available is necessarily course, the amount limited. Dr. Chisolm appears to contemplate interfering only with the pillars of the external abdominal ring, but in the present case it was obviously necessary to close the deeper opening in the conjoined tendon, and I need not say that care is necessary in transfixing the abdominal structures at such a depth : by doing so, however, from within outwards, and keeping the point of the needle anterior to the guiding finger all risk of wounding the peritoneum is, with ordinary care, avoided.
Sehoee,
jFebruary 1878.
[June 1,
1878.
A CASE OF DIRECT INGUINAL HERNIA. By Surgeon-Major F. Odevaine, F.K..C.S.
The
a well-developed, tall, muscular man, aged about native of Jeddali, was admitted into the Sehore Dispensary for sinus of the right side of the chest, extendiug between the pectoral muscles. He had also a right direct inguinal hernia, which came down only when he waited, and which, though not very large, yet gave him a good deal of annoyance, so much so, that be expressed a strong wish to be permanently cured of it. He stated the hernia first appeared three years ago. On reducing the protrusion, and forcibly pushing the index finger upwards and backwards through the external abdominal ring, its point becomes engaged in an opening in the conjoined tendons, immediately to the outer margin of the right rectus, or, more correctly speaking, the pyramidalis muscle, when it is present; the base of the opening is formed by a part of the transverse ramus of the pubes, and the sides somewhat lunated meet above in the form of an arch. If the patient is desired to cough strongly, the hernia is felt to impinge on the point of the finger, occupying the opening alluded to. Some days after the patient's admission into the dispensary, having given him a suitable aperient, the pube3 was shaved I took and he was placed on his back on the operating table. a slightly curved long needle, the eye near its point, and fixed in a strong handle, the convexity of the needle I placed on the palmar aspect of my right index finger, the handle of the instrument being firmly fixed by the thumb and other fingers of the same hand. I then pushed the centre of the scrotum of the right side upwards until the finger and needle were engaged in the hernial opening, when the inner tendinous margin of this was transfixed, the point of the needle being directed upwards, fowards and a little outwards, and made to protrude through the integument at about two inches above the aperture in the conjoined tendons. A strong piece of pure silver wire which was then was passed through the eye of the needle, partly withdrawn, but not wholly removed from the point of entrance in the scrotum : the direction of the needle was next changed in such a way that it, with the engaged loop of wire, made a sweep outwards, and then its point guided by the forefinger was made to perforate the external pillar of the hernial opening from within outwards, and, by having the skin of the abdomen drawn in an external direction, the needle made its exit through the first aperture in front; the wire having been removed from the needle, the latter -was withdrawn. There were thus four strands of silver wire left protruding through the anterior puncture, their ends were firmly twisted, the right thigh being flexed and bent inwards, so as to relax the abdominal walls and allow of the approximation of the sides of the opening in the conjoined tendons, the twisted ends were cut close off and the skin pulled upwards, which allowed the wire to disappear in a direction towards the pubes. A spica bondage was applied and the patient directed to remain in bed. After the operation it was found that the centre of the scrotum on the right side still remained invaginated, probably owing to the needle in its sweep outwards, and before transfixing the external pillar of the hernial opening, having caught some fascia of this part and : ept it tucked up. This had, however, disits normal appeared by the next day, and the scrotum resumed allowed to walk position. Some days after, the patient was about, the bandage beingkept applied, and he complained of not the 1 a9t pain in the part, except when firm pressure was made over the vicinity of the external abdominal ring, in which situation the wire could be indistinctly felt. On the fourteenth day after the operation the bandage was removed, and the man permitted to move about, and no further protrusion of the but unfortunataly I waa prevented from took
30, and
patient,
rupture
a
place,
1
/
THE INDIAN MEDICAL GAZETTE.
156
testing the effect of much walking or violent exercise, 33 the patient without any apparent reason absconded. The above operation for the radic.il cure of hernia was first described and put into practice by Dr. J. J. Chisolm of the South Carolina Medical College as far back as 1859, and has the advantage of being simple, and, with care, free from danger. In cases in which the opening in the abdominal walls is very large, I should think it unBiiited, as its success depends greatly of the scrotum partly filling upon the invaginnted structures which the hernia protruded, and, ot' up the aperture through of structure thus available is necessarily course, the amount limited. Dr. Chisolm appears to contemplate interfering only with the pillars of the external abdominal ring, but in the present case it was obviously necessary to close the deeper opening in the conjoined tendon, and I need not say that care is necessary in transfixing the abdominal structures at such a depth : by doing so, however, from within outwards, and keeping the point of the needle anterior to the guiding finger all risk of wounding the peritoneum is, with ordinary care, avoided.
Sehoee,
jFebruary 1878.
[June 1,
1878.
