1897 Journal of the American Medical Association (JAMA)  
that it is only with those dangers which attend mortification that we have to deal because with this imperfect hernia comes a tumor. The only case that I have met was an old man of 76 in whom there was a tumor the fourth day afterward. The symptoms of strangulation are not constant, but may approach shock. It is important to detect this in time, and 1 believe the condition referred to in the paper is much more common than is generally supposed. Dr. Miles P. Porter of Indiana-I know that this
more » ... I know that this condition does occur and occurs acutely, for I remember a case occurring in a female child twenty-two months old. The diagnosis was made and operation revealed a Littre's hernia with strangulation. Dr. G. G. Davis of Philadelphia-I remember an old lady about sixty years of age who was brought into the hospital after having suffered with symptoms of strangulated hernia for about ten days. I thought it was a Littre's hernia of a portion of the intestinal wall, and in the diverticulum. On operation I found there was a cancerous body embracing onequarter of the circumference of the gut and about one inch long. This pointed definitely to the fact that a partial strangulation of the gut itself occurred, and goes to show that the only history is one of length and not acute. Dr. Smith-The fact that we have symptoms of strangulated hernia with the passage of gas has been proven. We sometimes incline to err because the existing symptoms are not compatible with the conditions. It is important for every one to appreciate the fact that whenever a hernia is strangulated it should either be reduced easily and promptly, or treated by operation. The danger from the operation is very much less than from the excessive use of taxis. Having this additional danger brought before us today, it is very likely to save many a patient from excessive taxis. Dr. J. McFadden Gaston of Atlanta, Ga.-1 saw four cases of this particular kind of hernia before I recognized the character of the trouble, and in three of them I succeeded in reduction by taxis. The evidence was very conclusive of the existence of the hernia. In one case I used taxis to a considerable extent, under anesthesia. After letting the patient rest, and using asefedita and belladonna, I was able to reduce it by taxis. I was called in consultation in another case in which we all agreed that it was a case of obstruction of the bowel of some form and we agreed that possibly it might be an indurated gland. The symptoms all pointed to bowel obstruction, however, and we treated upon this principle. The case went on to the point when there was an indication of liquid formation and fecal extravasation, death ensuing. I thought we would find a partial dislocation of the intestine, which was verified. Dr. E. Tappey of Detroit, Mich.-As to the condition of the intestine in the first diagram that was shown, in a Littre's hernia, a portion of the intestinal wall becomes herniated and my conception is that there is necessarily a formation of an angle on the opposite wall of the hernia. I suppose that if the intestine gets into the position shown in the diagram, it must be that the hernia has become chronic and adhesions have formed. The intestine becomes distended, but I do not think that this condition can exist in an acute condition. I have seen this condition of Littre's hernia where a portion of the intestine had become herniated in the median line just below the diaphragm. Dr. E. D. Ferguson of Troy-My observations in these cases have been where the hernial protrusion has been much drawn out of the usual sites. I wish to speak of one point in the management of the case. Usually when we have hernias of this kind and succeed in reducing them, we must take into consideration the extreme liability of adhesions in the intestinal cavity. The wisest surgical procedure would be to proceed at once to the obliteration of the hernia canal. Dr. Burns of Long Island City-1 have had one case with symptoms of intestinal obstruction, although it was not considered by the doctor in attendance that the hernia accounted for the symptoms. I was called in and examined all the points referring to the possibility of hernia. There did not seem to be enough of importance to warrant us in saying what it might be and we removed the patient to the hospital to operate on her. During the operation I opened a sac and introduced my finger to examine it when I found that something had sunk back from the inguinal canal. I found the inguinal glands quite free. I concluded to close the canal and we decided not to explore with a further incision in this particular case. The symptoms became better after the operation and in ten days the patient left the hospital. I kept her on a suitable diet and there was some slight rise of temperature. We let her leave the hospital in a spring wagon, and she traveled about one and a half miles on a country road. Upon arriving home she ate a German dish and I was called to see her a few hours afterward, when she died suddenly. My personal conviction was that she had omental hernia, but I am now convinced that she had a hernia of the kind mentioned today. I was very sorry that an autopsy could not be secured. I remember another case of a similar nature in a very stout woman. I had no proper apparatus for operation but I concluded to operate. I succeeded in replacing it through the natural aperture and she was able to leave off her truss which she had been wearing for a long time. Dr. Hatch of Quincy, 111.-There is a class of cases which can be very easily mistaken for obstruction to the bowels. I mean the class where there is a partial incrustation of the intestine. In these cases you will find attachments around the coating of the intestines which simulate incrustations, and you will also find that, on the sides of the intestine, the feces are in batches, leaving but a small opening, so that you have all the symptoms of an obstruction and some of those of a hernia, with intense pain. Such was the case that I saw, and I had one of the same kind about a month ago. By the application of warm fomentations and small repeated doses of calomel I was able to remove all but a few incrustations around the intestinal wall. Dr. Stahl-So far as the meaning of a Littre's hernia is concerned, it is mentioned to a considerable extent in French literature. Our friend from Detroit tells us that he had a case above the umbilicus, and Littre's second case was just such a one. This was the chronic form, which my own case must have been. My own case was purely a case of intestinal wall hernia. Littre's first hernia was one of Meckel's ganglia. We have two appendices in poultry, and when we have a Meckel's ganglia it is a very similar thing. This is well shown by the mesentery in poultry. The American Text-Book shows that, in the treatment of a Littre's hernia, we must understand hernias of all the parts of the diverticulum, whether congenital or acquired. So far as the term is concerned we must still use it as he first described both the congenital and the acquired forms. There are other forms which I have not been able to bring out. The only object that I have in presenting this paper is to state what is not usually well known, that the whole intestinal wall is not drawn out. Whether the case is congentital or acquired is important, and hard to decide. It is not an infrequent form of hernia. If we can prove that the acute form does occur we will then have brought much credit upon our meeting. The local use of dry heat has long been justly regarded as a valuable therapeutic agent in treating inflammations of the ear, otalgia, etc.; these applications in the form of hot salt and bran bags, or hot water bottles, however, are usually only made to the external ear, the actual amount of heat, therefore, coming in contact with the external auditory canal and membrana tympani is necessarily slight. It has often occurred to me, while treating various forms of ear diseases, that the direct application of heated dry air to the drumhead and middle ear would be desirable, provided we had an apparatus whereby the degree of heat could be regulated, and by the aid of which it could be readily obtained and applied. I have now such an apparatus, having found it to answer the desired purpose. It is a modification of an instrument which was first devised for the purpose of dental surgery. It consists of a metallic bulb or barrel containing a piece of carbon, a rubber hand-ball aircompresser, and a long curved pointed steel nozzle. The bulb (or barrel) is heated sufficiently by being held over a flame, preferably that of a spirit lamp; a current of air is then forced through it by means of the hand ball, thus delivering a small stream of heated Downloaded From: http://jama.jamanetwork.com/ by a University of Iowa User on 06/16/2015
doi:10.1001/jama.1897.02440400027002g fatcat:qvnzlsqd5jbtnbfnw57e7slnn4