point outwards along guinal canal.
the
course
of the in-
The lower and inner portion crackled
on
pres-
sure, and was soft, yielding and tympanitic; the outer part was more resisting and dull on per-
% (Pupr of Hospital ?pttice. MEDICAL COLLEGE HOSPITAL, CALCUTTA. STRANGULATED RIGHT INGUINAL HERNIA-REEN BLOC?OPERATIVE FORMATION DUCTION OF ARTIFICIAL ANUS?RECOVERY.
( Under
the
rare
OffJ-
Reported by
of Surgeon-Major D. O'C. Itii/e, 31. D., !??? Surgeon of the Hospital.)
late
House-Surgeon
Amrita Lal Das.
Kritibash Giiosk, Hindu male, aged 20, admitted 17tli July 1884, at about 5 p. m.,
suffering
from
strangulated
right
inguinal
hernia of four days' duration. Vomiting had occurred several times previous to admission, adir mistered, and ice A soap-water enema applied to the tumour. He was also given a grain of opium to relieve pain. The patient stated that, until four days previous to his admission, he had never had anv trace of a hernia, but that having an altercation while eating, lie vomited several times, and the rupture occurred suddenly with severe pain. Various remedies were then applied, and later on taxis was vigorously applied under chloroform by a practitioner, with the result of a great decrease in the size of the tumour, which was thought to have been reduced; after this, croton oil was given to opera,te ou the bowel. The symptoms were unrelieved, vomiting continued, and great pain was felt in the region of the hernia, and thus up on the 4th day of the accident he sought, treatment in hospital. The visiting Surgeon Dr. Raye found the parts in the following condition: There was an elongated soft swelling in the right inguinoscrotal region. It was divided by an ill-marked sulcus into two portions, each about the size of an egg, one lying iu the i. per part of the scrotum and extending to the neighbourhood of the external ring, the other spreading from this
cussion ; no impulse could be felt on coughing. The abdomen was distended and tympanitic, pulse small and rapid, countenance anxious, pain severe, tongue dry, vomiting frequent, but not stercoraceous. Temperature normal. An incision about 2| inches long made, extending from above the external ring obliquely downwards. All the tissues were oede-matous. The sac was found to contain claret-coloured fluid, mixed with gas bubbles. When the sac was opened, a piece of deeply congested omentum came into view, lying below in contact with the testicle (the hernia proving to be congenital) and ab)ve tightly gripped at the external ring. Several bands of recent lymph covered the protrusion. The stricture at the external ring was next divided, and the recent adhesions were then
carefully separated.
Lying behind the omentum and actually in the external ring, a dark knucle of small intesThe omentum was next tine was now exposed. as it was in a state of and drawn down, slightly doubtful vitality and effectually opposed reduction,
it
was
ligatured
in two
portions,
and cut
The inguinal canal could uow be explored. off. It was found blocked up with a portion of the " en hernia, which had been evidently reduced bloc," and which had become adherent there, but the exact site of whatever deep constriction existed could not be made out clearly. The whole length of the inguinal canal had, therefore, to be laid open, and several receut adhesions separated step by step. On passing the finger through the situation of the inner ring, a tight baud was felt encircling a loop of still strangulated bowel? this was the orifice, apparently, of the trausversalis fascia, which structure had been stripped from the inner surface of the abdominal wall, and along with the hernia pushed backwards and upwards in the previous efforts at taxi*. With some trouble the constricting ring was drawn down again, exposed to view, and divided. The gut (a piece of small intestine) at this point was almost cut through, and seemed to have lost its vitality. The large incision was united by interrupted catgut and wire sutures. A drainage tube placed in the scrotal angle. The upper end of the wound was left open, corresponding to the site of the most, severely injured piece of bowel, as it was thought not improbable that an artificial anus tniiiht form here. Carbolized dressings were applied, and the patient put to bed; a full dose of opium was then given. After the operation the patient felt much relieved, and copious thin bilious offensive stools escaped through the anus?no doubt the result of the crotou oil; he was allowed to take
opiura
THE INDIAN MEDICAL GAZETTE.
216
Tlie dressings admission. day. On the 6th day lie felt some fluid oozing through the wound, and on removing the dressings, the edges of wound were found sloughy and covered with escaped feces The abdomen in the meanfrom the intestine. time became painful, tympanitic and distended. For six days the patient passed his stools entirely through the artificial anus formed by sloughing Tlie wound assumed a of the constricted gut. healthy character gradually, and became granulating. All this time it was left open, being only washed frequently with Condy's solution, and kept loosely covered by saw-dust pads impregnated with 2 percent solution of perchloride of mercury. The artificial anus closed on the 1st August 1884. A scrotal abscess formed below the line of hernial incision, and was opened on the 28th July, and about 4 ozs of thick laudable pus let out. Patient now improved steadily, and the wound healed up by granulation, leaving a linear cicatrix 4\ inches long over the right could be felt on coughDistinct impulse groin. ing along this linear cicatrix. The cord was thickened. Patient was discharged cured on the 27th August 1884. Remarks.?This is altogether an unusual case, and shows clearly the dangers to which a person can be exposed by the employment of violent taxis and subsequent administration of croton oil. It is also curious to observe that while much anxiety was entertained on account of the distressing inconvenience of an artificial anus, nature came to the rescue and saved the patient from such life-long misery.
given were
before
changed
his
every
[July,
1885.
the
course
of the in-
The lower and inner portion crackled
on
pres-
sure, and was soft, yielding and tympanitic; the outer part was more resisting and dull on per-
% (Pupr of Hospital ?pttice. MEDICAL COLLEGE HOSPITAL, CALCUTTA. STRANGULATED RIGHT INGUINAL HERNIA-REEN BLOC?OPERATIVE FORMATION DUCTION OF ARTIFICIAL ANUS?RECOVERY.
( Under
the
rare
OffJ-
Reported by
of Surgeon-Major D. O'C. Itii/e, 31. D., !??? Surgeon of the Hospital.)
late
House-Surgeon
Amrita Lal Das.
Kritibash Giiosk, Hindu male, aged 20, admitted 17tli July 1884, at about 5 p. m.,
suffering
from
strangulated
right
inguinal
hernia of four days' duration. Vomiting had occurred several times previous to admission, adir mistered, and ice A soap-water enema applied to the tumour. He was also given a grain of opium to relieve pain. The patient stated that, until four days previous to his admission, he had never had anv trace of a hernia, but that having an altercation while eating, lie vomited several times, and the rupture occurred suddenly with severe pain. Various remedies were then applied, and later on taxis was vigorously applied under chloroform by a practitioner, with the result of a great decrease in the size of the tumour, which was thought to have been reduced; after this, croton oil was given to opera,te ou the bowel. The symptoms were unrelieved, vomiting continued, and great pain was felt in the region of the hernia, and thus up on the 4th day of the accident he sought, treatment in hospital. The visiting Surgeon Dr. Raye found the parts in the following condition: There was an elongated soft swelling in the right inguinoscrotal region. It was divided by an ill-marked sulcus into two portions, each about the size of an egg, one lying iu the i. per part of the scrotum and extending to the neighbourhood of the external ring, the other spreading from this
cussion ; no impulse could be felt on coughing. The abdomen was distended and tympanitic, pulse small and rapid, countenance anxious, pain severe, tongue dry, vomiting frequent, but not stercoraceous. Temperature normal. An incision about 2| inches long made, extending from above the external ring obliquely downwards. All the tissues were oede-matous. The sac was found to contain claret-coloured fluid, mixed with gas bubbles. When the sac was opened, a piece of deeply congested omentum came into view, lying below in contact with the testicle (the hernia proving to be congenital) and ab)ve tightly gripped at the external ring. Several bands of recent lymph covered the protrusion. The stricture at the external ring was next divided, and the recent adhesions were then
carefully separated.
Lying behind the omentum and actually in the external ring, a dark knucle of small intesThe omentum was next tine was now exposed. as it was in a state of and drawn down, slightly doubtful vitality and effectually opposed reduction,
it
was
ligatured
in two
portions,
and cut
The inguinal canal could uow be explored. off. It was found blocked up with a portion of the " en hernia, which had been evidently reduced bloc," and which had become adherent there, but the exact site of whatever deep constriction existed could not be made out clearly. The whole length of the inguinal canal had, therefore, to be laid open, and several receut adhesions separated step by step. On passing the finger through the situation of the inner ring, a tight baud was felt encircling a loop of still strangulated bowel? this was the orifice, apparently, of the trausversalis fascia, which structure had been stripped from the inner surface of the abdominal wall, and along with the hernia pushed backwards and upwards in the previous efforts at taxi*. With some trouble the constricting ring was drawn down again, exposed to view, and divided. The gut (a piece of small intestine) at this point was almost cut through, and seemed to have lost its vitality. The large incision was united by interrupted catgut and wire sutures. A drainage tube placed in the scrotal angle. The upper end of the wound was left open, corresponding to the site of the most, severely injured piece of bowel, as it was thought not improbable that an artificial anus tniiiht form here. Carbolized dressings were applied, and the patient put to bed; a full dose of opium was then given. After the operation the patient felt much relieved, and copious thin bilious offensive stools escaped through the anus?no doubt the result of the crotou oil; he was allowed to take
opiura
THE INDIAN MEDICAL GAZETTE.
216
Tlie dressings admission. day. On the 6th day lie felt some fluid oozing through the wound, and on removing the dressings, the edges of wound were found sloughy and covered with escaped feces The abdomen in the meanfrom the intestine. time became painful, tympanitic and distended. For six days the patient passed his stools entirely through the artificial anus formed by sloughing Tlie wound assumed a of the constricted gut. healthy character gradually, and became granulating. All this time it was left open, being only washed frequently with Condy's solution, and kept loosely covered by saw-dust pads impregnated with 2 percent solution of perchloride of mercury. The artificial anus closed on the 1st August 1884. A scrotal abscess formed below the line of hernial incision, and was opened on the 28th July, and about 4 ozs of thick laudable pus let out. Patient now improved steadily, and the wound healed up by granulation, leaving a linear cicatrix 4\ inches long over the right could be felt on coughDistinct impulse groin. ing along this linear cicatrix. The cord was thickened. Patient was discharged cured on the 27th August 1884. Remarks.?This is altogether an unusual case, and shows clearly the dangers to which a person can be exposed by the employment of violent taxis and subsequent administration of croton oil. It is also curious to observe that while much anxiety was entertained on account of the distressing inconvenience of an artificial anus, nature came to the rescue and saved the patient from such life-long misery.
given were
before
changed
his
every
[July,
1885.
