Reduplications of Mucous Membrane in the Upper Portion of the Tympanic Cavity, and Their Clinical Importance

1889 Boston Medical and Surgical Journal  
The patient had always had an undescended testicle on fhe left side, the organ having been arrested in its descent just outside of the inguinal ring in the groin. For many years he had also bad a hcr-11 i ill protrusion through the same ring, and this had troubled him several times by being for a time irreducible. On July 14th (three days before entrance) the hernia was down and caused discomfort. It did not go back easily, and was finally reduced with some difficulty under ether. When he
more » ... ther. When he recovered from etherization, it was found, however, that his symptoms were rather aggravated than relieved. He still had abdominal pain, especially in the left side ; and the vomiting continued persistently and presently became fecal in character. When he entered the hospital there was nothing to be felt in the abdomen or in the inguinal region, and the left testicle could not be found. The continuance of symptoms of strangulation made it clear that constriction of the bowels still existed somewhere, and a laparotomy was advised. This being agreed to an incision was made from over the sac of the hernia, upwards onto the abdo- men. On laying open the sac it was found empty, but following it up through the inguinal ring, a dilatation of the upper part of the sac was found inside the abdominal wall ; and this contained a purple loop of intestine. The neck between the upper part of this hourglass-shaped sac and the peritoneal cavity was formed by a thick band of fibrous tissue which represented the true neck of the sac and which would easily admit the end of the finger. It would have been amply large to allow of the return of the hernia, had it not been blocked by the testicle, which lay across the opening and closed it as by a valve. The more the intestine was pressed up from below, the more closely did it force the testicle into the ring and close it. On relaxing the parts and pulling down upon the sac so as to draw the testicle away from the orifice, the bowel slipped up quite easily. A further examination was made of the contents of the abdomen to make sure that no other constriction or injury of the intestine existed, but nothing was found. In closing the wound, the neck of the sae was drawn together by encircling stitches for a distance of an inch and a half to two inches, and care was taken that the uppermost stitches should be well within the abdomen, so that no depression should be left on the peritoneal side of the ring. The patient was entirely relieved of his symptoms and made a rapid and good recovery, leaving the hospital well on August 8th, twenty-two days from the time of entrance. This mail was heard from in February, 1889 (six months after the operation), and he then wrote that although he had worn no truss, there luid been no return of the hernia. He says in this letter, " I sometimes feel a smarting, burning feeling if 1 work very hard or lift anything very heavy ; this is all." In this case we had a rather rare complication of hernia, and a good example of the difficulty that an nndesceiidod testis may cause. It adds one to the many cases illustrative of the importance of a prompt laparotomy when symptoms of strangulation persist after the seemingly complete reduction of a hernia. One point noticed in this last case may be of practical importance in guiding us to the proper application of taxis under similar conditions. As has been described, the testticle lay against the opening through the neck of tho sac, and closed it as by a ball valve. The more the pressure from below, the more complete was this closure of the , ring, so that the effort to push the bowel up made the obstacle even greater. When, on the other hand, the part of the sac which lay in the scrotum was pulled downwards it drew the. testicle, which was attached to the wall of the sac, away from the opening, and the bowel easily slipped up by it. In a similar case, during taxis, it is quite probable that by pulling forcibly down on the scrotum the testis might be held away from the ring and the return of the hernia thus be rendered possible. ' From what was seen in this case, it seems a proper rule that, in a hernia complicated by a testicle retained in the region of the inguinal canal, if strangulation occurs, every effort should bo made to draw down the testis by pulling on the lower part of the tunica vaginalis. And after the hernia has been restored to the abdominal cavity, the reduction shall not be considered complete until the testicle has again, by traction on the scrotum, been drawn .down to its old resting-place, where it can be distinctly felt. In this way the danger of a reduction en bloc with the testis still occluding the neck of the sac will be made less probable, if not wholly avoided.
doi:10.1056/nejm188905301202204 fatcat:4zbgl5srgrbc7ioa6zaxk5haaq