Jflivror of Ijo.'ijjifitl frartite. MEDICAL COLLEGE
HOSPITAL, CALCUTTA.
TWO CASES OP STRANGULATED INGUINAL HERNIA OPERATED ON FOR RADICAL CURE.
Reported by Assistant-Surgeon
Amrita Lall Dass.
Case I.?Strangulated Bight Inguinal Hernia (Congenital) ; Operation for Radical Cure, and Castration of the Right Testis; Erysipelas and sloughing of the abdominal
parities
;
(Under the
Recovery.
care
Professor of
of
Surgeon-Major K.McLeod, M.A., M.D., Surgery, and First Surgeon, M. C. Hospital.)
Bhojohory Samonto, Hindu male, age 60, resident of Calcutta, admitted 24th February 1884, at about 7-30 a. m., suffering (from a strangulated right inguinal hernia, of 24 hours' duration. He stated that.the disease originated several years back, but the hernia was always reducible. Latterly he noticed a small tumour about the size of a duck's egg below the right groin; this always remained irreducible, and never gave him much trouble. He never wore a truss. On the morning of the 23rd at February 1884, 8 a. m., the rupture suddenly came down with a sharp pain, and got strangulated. He applied ice locally, and tried to reduce it by various local applications and manipulations, but without any efFeqt. The visiting found the surgeon Dr. McLeod (following condiThe tumour was found tions on admission. to occupy the right groin and right side of the scrotum : it was about the size of au orange, soft and yielding on pressure ; percussion note dull
builder,
148 all
THE INDIAN MEDICAL GAZETTE.
the tumour, and there Avas slight impulse Patient complained of severe in the part, had vomited three times since the descent of the heruia, but had no stool ; his general health was bad, being an old emaciated man with subnormal temperature, and small soft and frequent pulse. Steady application of taxis under chloroform failed to reduce the rupture; the patient was, therefore, placed on the table, and operation for the immediate relief of strangulation performed, under chloroform and with strict antiseptic precautions, at 8-30 a.m. (one hour after admission). The over
coughing. dragging pain on
exposed by ati oblique incision, long, over the l ight groin, "the soft parts, including the different layers of fascia) covering
sac
was
inches
the sac, being previously divided on a director." The sac whs opened and found to be continuous with the tunica vaginalis testes (congenital hernia). It contained a little tinted fluid and a knuckle of congested small intestine about 4 inches long; the stricture being found at. the neck of the sac, it was freely divided by a hernia knife, and the herniated gut carefully replaced. The sac was then dissected out from all attachments, but on pulling up the .fundus, the right testis, about the size of a bean, greatly atrophied, came into view. Such bei ng the condition of parts, castration of the right testis and radical operation for hernia was at once performed ; and the sac, including the right cord and testes, was ligatured at the neck by several knots of catgut, and the whole thing amputated at the level of the external ring, and the stump pushed within the inguinal canal. The pillars and conjoined tendons brought together by double catgut thread passed through a hernia needle, and wound being thoroughly washed with strong carbolic (1 in 20) lotion was stitched with interrupted wire and horse-hair stitches. A conter-opening made in the right side of the scrotum, and a drainage tube passed through it as far as the lower angle of the hernial wound. Dressings of boracic lint and carbolic gauze applied, and patient put to bed with a full dose of opium. Operation was followed by tympanitis, fever, and tenderness over the abdomen. Temperature rising to 100? F. On the fourth day, discharge from the wound became foetid and grainous, and pain on the abdomen was localized over the ricrht iliac region. On the fifth day, diffuse cel1 uTits of the abdominal wall, with crysepilatous rash appeared over the right iliac region. The inflammation rapidly extended over the right lumbar region, and reached as high as the iliac crest; the wound in the meantime became gangrenous, and the edges sloughed altogether. Profuse and repeated secondary haemorrhage took place from the partially lacerated vessels in and around the wound. The patient was at once put under a ferruginous tonic and
[May,
1885.
of potash, and the wound freely laid open to the extent of about six inches, and dressings impregnated with strong solution of sulphate of iron applied locally, which acted both as an antiseptic and stvptic. Milk, strengthening broths, and brandy were freely administered to the patient to support his failing strength. In this way a fortnight passed, during which period he was in a most critical condition. Temperature ranged between 98? and 100? F., with small, soft andrapid pulse, restlessness, and dry brown coated tongue. Gradually the erysipelatous inflammation subsided, and the sloughs separating, healthy granuThe stump lations appeared in the wound. of the divided cord and sac, with the ligature, came away as slough, on the 11th March 1884. Patient now improved steadily, and the wound healed up by granulation, leaving a linear cicatrix over the right iliac region, which imHe parted a distinct impulse on coughing. remained in hospital for two months and three days, and was discharged cured on the 27th May It is now 13 months since the operation 1884. the patient is doing well, and there is no sign of the recurrence of hernia. Remarks.?This is an unexpected recovery, considering the patient's weak state of health and feeble resisting powers to combat against the extensive sloughing of the wound and of the abdominal parietes that followed gangreIt is also curious to note that nous cellulitis. the stump of the sac and the castrated cord, with the ligatures, came away in a piece of
chlorate
slough.
Case No.
Operation for
II.
Strangulated Right Inguinal Recovery.
Ilernia:
Radical Cure ;
(Under
the care of Dr. K.
McLeod.)
Ashootosh Sanval, Brahmin, age 55 years, resident of Calcutta, occupation sarkar, admitted 25th February 1884, at about 4-45 P.m., suffering from strangulated right inguinal He stated that hernia of four hours' duration. the disease originated 25 years ago, and after five years he submitted to an operation for radiThe disease gave cal cure in this hospital. him no trouble for a few years after operation, and was apparently cured ; but the hernia gradually reappeared, and continued to descend occasionally at irregular intervals, notwithstanding his wearing a truss to check its progress. Hitherto it has always been a reducible one, but this afternoon, at 1 p.m., it spontaneously came down when he was seated and got strangulated. He tried to put it back by manipulation with his own hands, and failing to do so came to the hospital for relief. On admission, the patient was found old and of a weakly constitution with the arcus The hernial tumour senilis well marked. occupied the right scrotal bag and right side of the root of the penis; it was about the size a
Hay, 1885.] of a neck
STRANGULATED HERNIA?POTENTIAL CAPACITY OP BLADDER.
"
bael fruit," soft and elastic on pressure, rigid and hard, percussion note dull all over except at the neck, where it was resonant, no impulse on coughing, no gurgling, the right testicle was pushed down at the bottom of the scrotum, a linear depressed cicatrix, about 3 inches long, over the right groin, marked the site of former operation. The patient had a subnormal temperature, 96?F., with small intermittent and slow pulse. He had no vomiting and 110 stool since the descent of the hernia, but he was restless on account of a severe dragging pain in the tumour. Stead}' and well applied taxis under chloroform for 15 minutes, even after the emptying of a hydrocele sac of 6 ozs. of fluid, failed to reduce the rupture. Operation for the relief of strangulation at once decided and performed by Dr. McLeod under chloroform and with strict antiseptic precautions Sac exposed by an hours after admission. 3 inches over the right incision, long, oblique groin, baud of stricture outside the neck of the sac freely divided by a hernia knife and taxis re-applied. This, however, did not reduce the hernia, consequently the sac was opened, its cavity contained a large mass of intestine, a little omentum, and some highly tinted fluid. The coils of intestine formed a double loop, one passing through the other, besides being adherent to each other by old adhesions ; the vermiform appendix about 5 inches long was also found floating within the sac; a portion of the healthy On examining the intestine was drawn down. herniated gut, a greater portion of it was found of a dark mahogany colour from intense congestion ; and a rent about 1 inch long detected in the peritoneal coat; the coils of intestine could not be separated on account of old cicatricial adhesions, consequently the whole of the herniated structures were carefully replaced by gently manipulating with the indexflngers of both hands.
The
next dissected out from all attachligatured at the neck by several knots of thread, and amputated at the level of the
sac was
ments,
catgut
Pillars and conjoined tendons double catgut thread a in two places, in needle a hernia passed through order to close effectively the widened ring. The wound was now washed with strong carbolic lotion, and closed with interrupted wire and horse hair stitches; a conter-opening made of the right side of the scrotum, and a drainge tube passed through it as far as the lower angle of the hernial wound. Dressings of boracic lint and carbolic gauze applied. After the operation, the patient had slight tympanitis and tenderness over the abdomen for about four days. His temperature continued subnormal for two days, but reaction setting in it rose to 107? F. on the next day. Being a high caste Brahmin, he was kept exclusively on milk-diet, and allowed Tinct. Camph. Co. Tinct. Cardamom Co. and Spt. external
ring.
brought together by
149
Amnion. Aromat, of each (3 ss.) half a drachm, On the every four hours, for the first four days. fifth day bowels moved freely, and much of the abdominal tenderness and tympanitis subsided. The drainage tube was removed on the third day after the operation, and the wound dressed altogether 16 times at intervals of two to four days with antiseptic dressings. It healed up partly by first intention and partly by granulation in course of a mouth. Patient remained in hospital for one month and eight days, and was discharged cured with a well fitting truss 011 the 4th April 1884. At the time of discharge the inguinal canal was found completely obliterated, there being 110 impulse on coughing beyond the inter nal ring, slight thickening of the cord remained. It is now thirteen months since the operation, and the patient is attending to the daily advocation of his life without any trouble, and there is 110 sign of the recurrence of the hernia. Remarks.?In this case the intense congestion of the herniated structures, and the reut in the peritonial coat of the bowel, following upon a strangulation of four hours' duration, can be only accounted for by the tightness of the stricture. Further, it clearly proves the necessity of prompt operative interference in cases of strangulated hernia, when afew hours' delay may end in disastrous results. Another fact of importance in this case is, that although the herniated bowels, when put back into the abdomen, were a mass of intricate coils matted together by old adhesions of a fibrous nature, yet, by the wonderful adaptation of nature, no untoward symptoms followed.
HOSPITAL, CALCUTTA.
TWO CASES OP STRANGULATED INGUINAL HERNIA OPERATED ON FOR RADICAL CURE.
Reported by Assistant-Surgeon
Amrita Lall Dass.
Case I.?Strangulated Bight Inguinal Hernia (Congenital) ; Operation for Radical Cure, and Castration of the Right Testis; Erysipelas and sloughing of the abdominal
parities
;
(Under the
Recovery.
care
Professor of
of
Surgeon-Major K.McLeod, M.A., M.D., Surgery, and First Surgeon, M. C. Hospital.)
Bhojohory Samonto, Hindu male, age 60, resident of Calcutta, admitted 24th February 1884, at about 7-30 a. m., suffering (from a strangulated right inguinal hernia, of 24 hours' duration. He stated that.the disease originated several years back, but the hernia was always reducible. Latterly he noticed a small tumour about the size of a duck's egg below the right groin; this always remained irreducible, and never gave him much trouble. He never wore a truss. On the morning of the 23rd at February 1884, 8 a. m., the rupture suddenly came down with a sharp pain, and got strangulated. He applied ice locally, and tried to reduce it by various local applications and manipulations, but without any efFeqt. The visiting found the surgeon Dr. McLeod (following condiThe tumour was found tions on admission. to occupy the right groin and right side of the scrotum : it was about the size of au orange, soft and yielding on pressure ; percussion note dull
builder,
148 all
THE INDIAN MEDICAL GAZETTE.
the tumour, and there Avas slight impulse Patient complained of severe in the part, had vomited three times since the descent of the heruia, but had no stool ; his general health was bad, being an old emaciated man with subnormal temperature, and small soft and frequent pulse. Steady application of taxis under chloroform failed to reduce the rupture; the patient was, therefore, placed on the table, and operation for the immediate relief of strangulation performed, under chloroform and with strict antiseptic precautions, at 8-30 a.m. (one hour after admission). The over
coughing. dragging pain on
exposed by ati oblique incision, long, over the l ight groin, "the soft parts, including the different layers of fascia) covering
sac
was
inches
the sac, being previously divided on a director." The sac whs opened and found to be continuous with the tunica vaginalis testes (congenital hernia). It contained a little tinted fluid and a knuckle of congested small intestine about 4 inches long; the stricture being found at. the neck of the sac, it was freely divided by a hernia knife, and the herniated gut carefully replaced. The sac was then dissected out from all attachments, but on pulling up the .fundus, the right testis, about the size of a bean, greatly atrophied, came into view. Such bei ng the condition of parts, castration of the right testis and radical operation for hernia was at once performed ; and the sac, including the right cord and testes, was ligatured at the neck by several knots of catgut, and the whole thing amputated at the level of the external ring, and the stump pushed within the inguinal canal. The pillars and conjoined tendons brought together by double catgut thread passed through a hernia needle, and wound being thoroughly washed with strong carbolic (1 in 20) lotion was stitched with interrupted wire and horse-hair stitches. A conter-opening made in the right side of the scrotum, and a drainage tube passed through it as far as the lower angle of the hernial wound. Dressings of boracic lint and carbolic gauze applied, and patient put to bed with a full dose of opium. Operation was followed by tympanitis, fever, and tenderness over the abdomen. Temperature rising to 100? F. On the fourth day, discharge from the wound became foetid and grainous, and pain on the abdomen was localized over the ricrht iliac region. On the fifth day, diffuse cel1 uTits of the abdominal wall, with crysepilatous rash appeared over the right iliac region. The inflammation rapidly extended over the right lumbar region, and reached as high as the iliac crest; the wound in the meantime became gangrenous, and the edges sloughed altogether. Profuse and repeated secondary haemorrhage took place from the partially lacerated vessels in and around the wound. The patient was at once put under a ferruginous tonic and
[May,
1885.
of potash, and the wound freely laid open to the extent of about six inches, and dressings impregnated with strong solution of sulphate of iron applied locally, which acted both as an antiseptic and stvptic. Milk, strengthening broths, and brandy were freely administered to the patient to support his failing strength. In this way a fortnight passed, during which period he was in a most critical condition. Temperature ranged between 98? and 100? F., with small, soft andrapid pulse, restlessness, and dry brown coated tongue. Gradually the erysipelatous inflammation subsided, and the sloughs separating, healthy granuThe stump lations appeared in the wound. of the divided cord and sac, with the ligature, came away as slough, on the 11th March 1884. Patient now improved steadily, and the wound healed up by granulation, leaving a linear cicatrix over the right iliac region, which imHe parted a distinct impulse on coughing. remained in hospital for two months and three days, and was discharged cured on the 27th May It is now 13 months since the operation 1884. the patient is doing well, and there is no sign of the recurrence of hernia. Remarks.?This is an unexpected recovery, considering the patient's weak state of health and feeble resisting powers to combat against the extensive sloughing of the wound and of the abdominal parietes that followed gangreIt is also curious to note that nous cellulitis. the stump of the sac and the castrated cord, with the ligatures, came away in a piece of
chlorate
slough.
Case No.
Operation for
II.
Strangulated Right Inguinal Recovery.
Ilernia:
Radical Cure ;
(Under
the care of Dr. K.
McLeod.)
Ashootosh Sanval, Brahmin, age 55 years, resident of Calcutta, occupation sarkar, admitted 25th February 1884, at about 4-45 P.m., suffering from strangulated right inguinal He stated that hernia of four hours' duration. the disease originated 25 years ago, and after five years he submitted to an operation for radiThe disease gave cal cure in this hospital. him no trouble for a few years after operation, and was apparently cured ; but the hernia gradually reappeared, and continued to descend occasionally at irregular intervals, notwithstanding his wearing a truss to check its progress. Hitherto it has always been a reducible one, but this afternoon, at 1 p.m., it spontaneously came down when he was seated and got strangulated. He tried to put it back by manipulation with his own hands, and failing to do so came to the hospital for relief. On admission, the patient was found old and of a weakly constitution with the arcus The hernial tumour senilis well marked. occupied the right scrotal bag and right side of the root of the penis; it was about the size a
Hay, 1885.] of a neck
STRANGULATED HERNIA?POTENTIAL CAPACITY OP BLADDER.
"
bael fruit," soft and elastic on pressure, rigid and hard, percussion note dull all over except at the neck, where it was resonant, no impulse on coughing, no gurgling, the right testicle was pushed down at the bottom of the scrotum, a linear depressed cicatrix, about 3 inches long, over the right groin, marked the site of former operation. The patient had a subnormal temperature, 96?F., with small intermittent and slow pulse. He had no vomiting and 110 stool since the descent of the hernia, but he was restless on account of a severe dragging pain in the tumour. Stead}' and well applied taxis under chloroform for 15 minutes, even after the emptying of a hydrocele sac of 6 ozs. of fluid, failed to reduce the rupture. Operation for the relief of strangulation at once decided and performed by Dr. McLeod under chloroform and with strict antiseptic precautions Sac exposed by an hours after admission. 3 inches over the right incision, long, oblique groin, baud of stricture outside the neck of the sac freely divided by a hernia knife and taxis re-applied. This, however, did not reduce the hernia, consequently the sac was opened, its cavity contained a large mass of intestine, a little omentum, and some highly tinted fluid. The coils of intestine formed a double loop, one passing through the other, besides being adherent to each other by old adhesions ; the vermiform appendix about 5 inches long was also found floating within the sac; a portion of the healthy On examining the intestine was drawn down. herniated gut, a greater portion of it was found of a dark mahogany colour from intense congestion ; and a rent about 1 inch long detected in the peritoneal coat; the coils of intestine could not be separated on account of old cicatricial adhesions, consequently the whole of the herniated structures were carefully replaced by gently manipulating with the indexflngers of both hands.
The
next dissected out from all attachligatured at the neck by several knots of thread, and amputated at the level of the
sac was
ments,
catgut
Pillars and conjoined tendons double catgut thread a in two places, in needle a hernia passed through order to close effectively the widened ring. The wound was now washed with strong carbolic lotion, and closed with interrupted wire and horse hair stitches; a conter-opening made of the right side of the scrotum, and a drainge tube passed through it as far as the lower angle of the hernial wound. Dressings of boracic lint and carbolic gauze applied. After the operation, the patient had slight tympanitis and tenderness over the abdomen for about four days. His temperature continued subnormal for two days, but reaction setting in it rose to 107? F. on the next day. Being a high caste Brahmin, he was kept exclusively on milk-diet, and allowed Tinct. Camph. Co. Tinct. Cardamom Co. and Spt. external
ring.
brought together by
149
Amnion. Aromat, of each (3 ss.) half a drachm, On the every four hours, for the first four days. fifth day bowels moved freely, and much of the abdominal tenderness and tympanitis subsided. The drainage tube was removed on the third day after the operation, and the wound dressed altogether 16 times at intervals of two to four days with antiseptic dressings. It healed up partly by first intention and partly by granulation in course of a mouth. Patient remained in hospital for one month and eight days, and was discharged cured with a well fitting truss 011 the 4th April 1884. At the time of discharge the inguinal canal was found completely obliterated, there being 110 impulse on coughing beyond the inter nal ring, slight thickening of the cord remained. It is now thirteen months since the operation, and the patient is attending to the daily advocation of his life without any trouble, and there is 110 sign of the recurrence of the hernia. Remarks.?In this case the intense congestion of the herniated structures, and the reut in the peritonial coat of the bowel, following upon a strangulation of four hours' duration, can be only accounted for by the tightness of the stricture. Further, it clearly proves the necessity of prompt operative interference in cases of strangulated hernia, when afew hours' delay may end in disastrous results. Another fact of importance in this case is, that although the herniated bowels, when put back into the abdomen, were a mass of intricate coils matted together by old adhesions of a fibrous nature, yet, by the wonderful adaptation of nature, no untoward symptoms followed.
