1861 The Lancet  
237 an inch and a half. This having been done, the sac of a hernia a.* once bulged into view. It lay above and behind the testis, and on the sac having been opened was found to contain a knuckle of small intestine in a deeply congested state. On introducing the finger into the sac, its neck was found to be displaced upwards considerably within the internal ring, and it was only with considerable difficulty that it was brought down low enough to admit of safe division. The stricture, which was
more » ... ry tight, was the neck of the sac itself. & p o u n d ; The sac was very thin; it contained the testis, the hernia being of the congenital form. As soon as the stricture had been divided, the knuckle of bowel was easily returned. Before closing the wound, the testis was pushed under the lower flap of the incised integument, and the edges were then brought into accurate apposition by hare-lip pins. The after progress was favourable. For a few days the man had symptoms of peritoneal inflammation, but they were subdued by leeches and calomel and opium. Mr. Hutchinson remarked that the case illustrated in a i striking manner the correctness of the rule "when in doubt operate," and showed that the surgeon should rely rather on the constitutional than the local symptoms. The case proved that a man might have a tightly strangulated hernia, although he had no perceptible tumour externally, could bear the deepest pressure on the abdomen, and was almost free from pain. It was also of unusual interest as an example of reduction e2 masse. ST. MARY'S HOSPITAL. CONGENITAL INGUINAL HERNIA OF THE RIGHT SIDE; OPERATION; CONVALESCENCE ON THE FOURTH DAY. (Under the care of Mr. URE.) H. H-, aged thirteen, a boy, with a healthy complexion, was admitted Dec. 9th, 1860, at five with an oblique inguinal hernia of the right side. The swelling distended the scrotum, was of a flattened cylindrical form, exceedingly tense, and the seat of pain, which extended up along the crest of the ilium of that side. The mother perceived the hernia soon after birth ; the patient had not worn a truss for the last two years. The hernia became prominent three days prior to his admission-that is, the bowels had not been relieved for that period. Vomiting set in at noon the previous day. Pulse quick and irritable. The taxis was tried whilst the patient was in the warm bath, and also under the influence of chloroform, but proved ineffectual. At seven P. M. Mr. Ure per-I formed the usual operation. On laying open the sac, a knuckle ' , of intestine protruded, together with a portion of omentum, the veins of which were turgid with blood, making it resemble a mulberry. He then relieved the stricture at the internal ring, and replaced the protrusion. Three points of suture, with a compress and bandage, completed the dressing. Dec. 10th.-Slept extremely well during the night; countenance good; no complaint of any kind; pulse 100. Has taken some broth. llth.-Doing well; bowels acted spontaneously. 12th.-Wound united by adhesion; convalescent. 19th.-Walking about the ward. 28th.-Left cured, wearing a truss. The medicine administered to this patient during his stay in the hospital consisted of but one small dose of castor oil. WESTERN GENERAL DISPENSARY. STRANGULATED FEMORAL HERNIA FOR FOUR DAYS ; OPERATION ; RECOVERY, WITH AN ARTIFICIAL ANUS. (Under the care of Mr. BARKER.) THE following cases are from the notes of Mr. T. C. Kirby, house-surgeon to the institution :-Rose H-, aged thirty-three, was admitted on the 18th of January, 1861, at eight o'clock r.M. She was an extremely emaciated, ill-nourished woman; countenance anxious; skin cold; pulse over 100, very small and feeble; tongue slightly furred, white, and inclined to be dry; abdomen a little distended, not painful on pressure ; constant vomiting of stercoraceous matter; bowels have not been opened for four days. In the right femoral region was a swelling, painful on pressure, bout the size of an egg, not rising above the level of Poupart's gament ; the skin over the part red and cedematous. The patient is a married woman, the mother of seven child-ren, the youngest seven months old. Six years ago, after a labour, she perceived a swelling in the right groin, causing her great pain at the time. She has never been able entirely to return it, although its size varied; has never worn a truss. On January 13th she had an attack of vomiting and diarrhoea, since which time the vomiting has been constant; but an action of the bowels took place on the evening of Jan. 15th. Scarcely any attempt to reduce the hernia was made by Mr. Barker, as many previous attempts had already been made. Chloroform was administered, and the operation forthwith commenced. After dissection of the superjacent structures, a dark-coloured sac was exposed. This was opened, and found to contain omentum, with a knuckle of intestine behind and internal to it. The gut was of a deep-brown colour, soft, flabby, and dull, covered with greyish spots. The condition of the intestine did not warrant its return to the abdomen. It was accordingly laid open to the extent of an inch. It appeared greatly thickened and infiltrated. A portion of the omentum was removed, and, as there was no hemorrhage, nothing further was done. Lint dipped in cold water was applied to the wound. A grain. of opium was given immediately after the operation, and repeated every three hours through the night and next day. She had brandy amounting to twelve ounces in the first twelve hours, with beef-tea occasionally. Jan. 19th.-She had slept well; vomited offensive matter of a bilious colour twice during the day. At ten o'clock P.M. she had two grains of opium, and two grains again at three o'clock A.M. 20th.-Had a good night; tongue a little brown in the centre; pulse 90; there is a free discharge of iseca.1 matter through the wound, the latter inclining to slough; the bowel looks healthy; complains of thirst; vomiting more constant, still apparently bilious. To have two grains of calomel and one of opium every four hours. After taking two doses the vomiting ceased. :she was then ordered a grain of opium every six hours and two grains at bed-time. 21st.-Slept for four hours at intervals during the night; tongue moist, white; pulse 98; skin a little dry; feels feverish. Ordered a mixture containing citrate of ammonia, a grain of opium twice a day and two grains at bed-time ; brandy frequently, and jelly. 22nd.-Had slept well; pulse 84; tongue moist; no pain nor thirst; abdomen flaccid. Ordered a grain of opium every six hours. 23rd.--Still doing well; feculent matter discharging freely from the wound, from which a grumous fluid oozes on pressure at its inferior part; poultices of linseed meal kept constantly applied. To continue the opium, and to take two grains of quinine thrice a day. 24th.-Hacl a comfortable night. 25th.-Wound discharges pus from lower margin; there is still a slough in the wound, but not extending. Quinine increased to three grains thrice daily. 27th.-Had a bad night in consequence of the quantity of opium being reduced; bowels much relaxed; stools offensive. 28th.-Ordered two grains of opium again at night, and chalk mixture. After this the motions were more solid and less frequent. Passed a good night; tongue clean and moist; no pain. To have a chop daily, and continue brandy and opium twice a day. 29th.-A large slough was removed from the wound, which now appears healthy. To discontinue poultices, and use a dressing of simple cerate upon lint. 31st.-Progressing slowly; has had a solid motion twice a day through the wound, which is contracting. I Feb. 9th. -Had occasional returns of the diarrhoea, con-trolled in a great measure by various vegetable astringents; sits up in bed; is gaining flesh a little; still has a grain of opium twice or thrice a day, and a grain at bed-time, repeated. if she does not sleep. llth.-The wound is contracting daily, and in spite of a too free action of the bowels the patient is improving; sits up in the bed, and is occupied during most of the day at needlework. From the time of operation on the 18th to two on the 2uth the patient had taken sixteen grains of solid opium.
doi:10.1016/s0140-6736(02)41933-2 fatcat:6xchv4rtkzcr5afjzqbgo3emq4