CASE OF STRANGULATED, OBLIQUE, INGUINAL
HERNIA; OPERATION; RECOYERY. By Dr. JOHN G.
Assistant-Surgeon, Bengal Surgeon
of
FRENCH,
Medical Service; Mymensingh.
Civil
Eam Churn Dey, aged 32 years, a Hindoo servant,, wag admitted into the charitable hospital at Mymensingh on the 23rd of June, 1855, it 6 o'clocii p. m., suffering from acute strangulated hernia. He was a spare, delicate looking man, and gave the following history of himself. About a year and half ago he first perceived a lump in his groin, which gradually increased until it passed down to his scrotum. He sometimes suffered from pains in the abdomen, and latterly, when tbe tumour became very large, from debility. He says that owing to its size it was a great inconvenience to him; but he On the never did anything for it, and never wore a truss. 22nd violent pains came on in the belly and scrotum, which he thought nothing of. Since the morning of the 23rd they became very severe and sickening, and towards evening he wag obliged to seek admission into hospital. When the native doctor in charge saw him, he tried to reduce the tumour, and put back the intestine. Failing, he put him into a warm bath, gave him tincture of opium, and again tried the taxis, without success. Knowing that the man was very dangerously ill, he sent for me, and I lost no time in going down. "When I arrived I fouud the patient very restless ; countenance anxious;
dragging
August 1,
MITFORD HOSPITAL STATISTICS.
1866.]
skin cool and clammy; pulse 120, small, quick, and weak; tongue coated, but moist; he had stercoraceous vomiting of offensive matter; and on examination I found a large oval
scrotal tumor, apparently
an
oblique inguinal hernia,
very elastic and tense of the touch ; there was no impulse communicated by coughing ; a prolongation of the tumour was traced into the inguinal canal, and when handled it was very painful. The bowels had been confined for the last two days; he had a desire to go to stool, although he could evacuate nothing. There was considerable tenderness over the abdomen, and coughing produced great pain. Seeing that the man Was in a very dangerous state, I put him immediately on the table, and under chloroform; Under the influence of the anesthetic, I tried to reduce the tumour, but without success. I next tried Sentin's plan (insinuating the tip of the finger into the constricting orifice, and dilating it forcibly), but found it of no use. I then proceeded to operate. The skin being made tense, an incision along the axis of the tumour, and about four inches in length, was made. The structures (which I need not here detail) covering the On coming down on the sac, I hernia were next divided. found it distended, .transparent, and containing serum and intestine. The sac was opened, and a quantity of fluid rushed forth. There was about one foot and a half of intestine, and The intestine was brownish some omentum exposed to' view. in color, with two very black, gangrenous-looking patches at end. I was as to whether they were ganthe lower puzzled grene or eccliymosis; but, on further and more minute examination, I came to the conclusion that they were ecchymosis, which in a very short space of time would have run into sphacelus. I determined on letting them alone, and returning the intestine, &c. Passing my finger up the canal, I detected the stricture at the internal ring. I passed a curved, bluntpointed bistoury flat on the finger through the stricture, and turning up the edge, I divided directly upwards. The intestine was returned bit by bit, and next the omentum. The wound was closed by sutures and a firm wet compress, and bandages were applied. He was placed in bed, and xl. minims of tincture of opium were given. June 24:th, 6 a.m.?Slept a little during the night; tongue coated, but moist; pulse 100, but soft; suffers no pain, but has slight tenderness over the abdomen; no fever; wound not disturbed. i. Pulv : opii Ordered? v gr.
nearly
as
large
as
infant's head.
an
It
was
.
3tis horis sumend. Sago and milk diet.
Vespere.?Generally
in the same state as last visit, but is in the stomach;
hiccough; has slight pain powder. vi\ xxv Jt, Tinct: hyoscami Tinct: opii in xv m h Liquoris potassae Spiritus etheris sulph:.. r>\ xxv Mist: camphoris ^ss. in
troubled with severe vomited once. Omit
.,
..
..
Ft haustus.
3tis horis sumend.
Emplast: sinapis. Abdom. applicetur. 25th, 6 a.m.?Slept during the night; still troubled with hicand cough vomiting ; pulse softer and fuller; slight tenderness over the abdomen ; wound looks well ; skin cool; hates lying on his back.
Ordered.?A few drops of dilute hydrocyanic acid to be given with each dose of medicine ; omit tincture of opium, and give an enema.
Vespere.?Bowels were opened freely after the enema ; hiccough much less frequent ; no vomiting, no pain or tenderness over the abdomen ; slept during the day ; eats his food well; cold water dressing applied again to wound. Ordered.?Continue mixture, but omit acid hydrocyanic dilute. 26th.?Hiccough has disappeared ; wound looks healthy, and is discharging matter; no pain ; had a slight fever of an intermittent type. Ordered.?Omit medicine ; give ^ss. of quinine mixture, (grs. v ad. gj) every third hour. Give goat-soup in addition to his sago and miik diet. 27th.?Bowels freely opened during the night; passed a regular cast of the intestine, about three inches long ; feels no pain ; had no fever during the night; maggots appear in the wound, notwithstanding all the care that has been taken to keep flies away; one maggot was withdrawn with a forceps. A fewdrops of the following mixture were immediately put into
'221
different parts of the wound:?camphor 3jss., spiritus vini rectif ?ss., spiritus terebinth gss. In a very short time three or four maggots came to the surface and were withdrawn?ordered the wound to be dressed with an ointment containing camphor, creosote, and turpentine. Give the quinine mixture only three times
a
to-day ; continue same diet. Vespere;?Withdrew two more maggots.
They evidently had as before; health
nest in the bottom of the wound; dressed
improving'.
28th.?Bowels again open freely and naturally; some dead maggots were discharged with pus; feels very well, and wants to sit up ; wishes for rice and dal; ordered to let him have some
instead of sago; omit quinine. He went on this way for several days, at one time well, at another time suffering from intermittent fever (which kept him back very-much), but presenting nothing interesting or worthy of record. Owing to his debility and delicate state of health, his recovery was slow. He was discharged, perfectly cured and able to work, on the 30th of August, 1865. Kemarks. As I think the foregoing case may prove interesting, I have given it fully ; therefore no remarks are necessary from me. We, however, see that there is no occasion for purgatives immediately after the operation; that unless the intestine i3 perfectly gone in gangrene, we had better leave it alone, .and trust to nature ; that hiccough may be very troublesome, and very persistent, without any bad.effect resulting. I myself thought that the man had no chance of living when hiccough came on; that opium is the best medicine after the operation for producing rest and sleep; stopping the vermicular action of the intestines, and thereby acting as a sort of preventitive to peritonitis. An enema, after two days or so, and afterwards castooil, if necessary (which was not in this case), bring about a healthy action of the bowels. The case affords another illusr tration of the danger of delay, and shows the necessity of an minediate operation after the taxis has failed.
HERNIA; OPERATION; RECOYERY. By Dr. JOHN G.
Assistant-Surgeon, Bengal Surgeon
of
FRENCH,
Medical Service; Mymensingh.
Civil
Eam Churn Dey, aged 32 years, a Hindoo servant,, wag admitted into the charitable hospital at Mymensingh on the 23rd of June, 1855, it 6 o'clocii p. m., suffering from acute strangulated hernia. He was a spare, delicate looking man, and gave the following history of himself. About a year and half ago he first perceived a lump in his groin, which gradually increased until it passed down to his scrotum. He sometimes suffered from pains in the abdomen, and latterly, when tbe tumour became very large, from debility. He says that owing to its size it was a great inconvenience to him; but he On the never did anything for it, and never wore a truss. 22nd violent pains came on in the belly and scrotum, which he thought nothing of. Since the morning of the 23rd they became very severe and sickening, and towards evening he wag obliged to seek admission into hospital. When the native doctor in charge saw him, he tried to reduce the tumour, and put back the intestine. Failing, he put him into a warm bath, gave him tincture of opium, and again tried the taxis, without success. Knowing that the man was very dangerously ill, he sent for me, and I lost no time in going down. "When I arrived I fouud the patient very restless ; countenance anxious;
dragging
August 1,
MITFORD HOSPITAL STATISTICS.
1866.]
skin cool and clammy; pulse 120, small, quick, and weak; tongue coated, but moist; he had stercoraceous vomiting of offensive matter; and on examination I found a large oval
scrotal tumor, apparently
an
oblique inguinal hernia,
very elastic and tense of the touch ; there was no impulse communicated by coughing ; a prolongation of the tumour was traced into the inguinal canal, and when handled it was very painful. The bowels had been confined for the last two days; he had a desire to go to stool, although he could evacuate nothing. There was considerable tenderness over the abdomen, and coughing produced great pain. Seeing that the man Was in a very dangerous state, I put him immediately on the table, and under chloroform; Under the influence of the anesthetic, I tried to reduce the tumour, but without success. I next tried Sentin's plan (insinuating the tip of the finger into the constricting orifice, and dilating it forcibly), but found it of no use. I then proceeded to operate. The skin being made tense, an incision along the axis of the tumour, and about four inches in length, was made. The structures (which I need not here detail) covering the On coming down on the sac, I hernia were next divided. found it distended, .transparent, and containing serum and intestine. The sac was opened, and a quantity of fluid rushed forth. There was about one foot and a half of intestine, and The intestine was brownish some omentum exposed to' view. in color, with two very black, gangrenous-looking patches at end. I was as to whether they were ganthe lower puzzled grene or eccliymosis; but, on further and more minute examination, I came to the conclusion that they were ecchymosis, which in a very short space of time would have run into sphacelus. I determined on letting them alone, and returning the intestine, &c. Passing my finger up the canal, I detected the stricture at the internal ring. I passed a curved, bluntpointed bistoury flat on the finger through the stricture, and turning up the edge, I divided directly upwards. The intestine was returned bit by bit, and next the omentum. The wound was closed by sutures and a firm wet compress, and bandages were applied. He was placed in bed, and xl. minims of tincture of opium were given. June 24:th, 6 a.m.?Slept a little during the night; tongue coated, but moist; pulse 100, but soft; suffers no pain, but has slight tenderness over the abdomen; no fever; wound not disturbed. i. Pulv : opii Ordered? v gr.
nearly
as
large
as
infant's head.
an
It
was
.
3tis horis sumend. Sago and milk diet.
Vespere.?Generally
in the same state as last visit, but is in the stomach;
hiccough; has slight pain powder. vi\ xxv Jt, Tinct: hyoscami Tinct: opii in xv m h Liquoris potassae Spiritus etheris sulph:.. r>\ xxv Mist: camphoris ^ss. in
troubled with severe vomited once. Omit
.,
..
..
Ft haustus.
3tis horis sumend.
Emplast: sinapis. Abdom. applicetur. 25th, 6 a.m.?Slept during the night; still troubled with hicand cough vomiting ; pulse softer and fuller; slight tenderness over the abdomen ; wound looks well ; skin cool; hates lying on his back.
Ordered.?A few drops of dilute hydrocyanic acid to be given with each dose of medicine ; omit tincture of opium, and give an enema.
Vespere.?Bowels were opened freely after the enema ; hiccough much less frequent ; no vomiting, no pain or tenderness over the abdomen ; slept during the day ; eats his food well; cold water dressing applied again to wound. Ordered.?Continue mixture, but omit acid hydrocyanic dilute. 26th.?Hiccough has disappeared ; wound looks healthy, and is discharging matter; no pain ; had a slight fever of an intermittent type. Ordered.?Omit medicine ; give ^ss. of quinine mixture, (grs. v ad. gj) every third hour. Give goat-soup in addition to his sago and miik diet. 27th.?Bowels freely opened during the night; passed a regular cast of the intestine, about three inches long ; feels no pain ; had no fever during the night; maggots appear in the wound, notwithstanding all the care that has been taken to keep flies away; one maggot was withdrawn with a forceps. A fewdrops of the following mixture were immediately put into
'221
different parts of the wound:?camphor 3jss., spiritus vini rectif ?ss., spiritus terebinth gss. In a very short time three or four maggots came to the surface and were withdrawn?ordered the wound to be dressed with an ointment containing camphor, creosote, and turpentine. Give the quinine mixture only three times
a
to-day ; continue same diet. Vespere;?Withdrew two more maggots.
They evidently had as before; health
nest in the bottom of the wound; dressed
improving'.
28th.?Bowels again open freely and naturally; some dead maggots were discharged with pus; feels very well, and wants to sit up ; wishes for rice and dal; ordered to let him have some
instead of sago; omit quinine. He went on this way for several days, at one time well, at another time suffering from intermittent fever (which kept him back very-much), but presenting nothing interesting or worthy of record. Owing to his debility and delicate state of health, his recovery was slow. He was discharged, perfectly cured and able to work, on the 30th of August, 1865. Kemarks. As I think the foregoing case may prove interesting, I have given it fully ; therefore no remarks are necessary from me. We, however, see that there is no occasion for purgatives immediately after the operation; that unless the intestine i3 perfectly gone in gangrene, we had better leave it alone, .and trust to nature ; that hiccough may be very troublesome, and very persistent, without any bad.effect resulting. I myself thought that the man had no chance of living when hiccough came on; that opium is the best medicine after the operation for producing rest and sleep; stopping the vermicular action of the intestines, and thereby acting as a sort of preventitive to peritonitis. An enema, after two days or so, and afterwards castooil, if necessary (which was not in this case), bring about a healthy action of the bowels. The case affords another illusr tration of the danger of delay, and shows the necessity of an minediate operation after the taxis has failed.
