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Un dee symbolee suivants apparattr* «ur la dernlAre imege de cheque microfiche, selon le caa: le symbols — »> signifie "A SUIVRE". le symbols V signifie "FIN". Maps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exposure ere filmed bt^ ginning in the upper left hand corner, left to right and top to bottom, aa many frames as required. The following diagrams illustrate the method: Les cartes, planches, tableaux, etc., peuvent Atre filmAe A dee taux de rAduction diff Arents. Lorsque le document est trop grand pour Atre reproduit en un seul clichA, 11 est fllmA A partir de I'angle supArieur gauche, de gauche A droite, et de haut en baa, en prenant le nombre d'Imeges nAcesssire. Les diagrammes suivants illustrent la mAthode. 1 2 3 1 2 3 4 5 9.0 :s^^.":s, SOME UNUSUAL CONDITIONS MET WITH IN HERNIA OPERATIONS. it JAMES liELL, M.D,, Montreal. (Repriv ltd from the Montreal Medical Journal, November, 1893.) :^s XTsr %. SOME UNUSUAL CONDITIONS MET WITH IN HKRNIA OPKRATIONS.^f- By James Bki,i., M.I)., Surgeon to tho Montreal (Icnenil Hospital ; Aesistiint Professor of Surgery and Clinical SurKory McGill University. As DUvigJitoi'H by common consent and for mutual benefit map out roofs, shouls and other impediments or dangers to navigation when they aro discovered, so, too, physicians and sui'geons for simihir reasons have adopted the method of re- coi'ding in the literaluio of the profession, such rare and unusual conditions, mot with from time to time, as may add to the sum of sciontltic knowledge and contribute to a better undoi'staiiding of its separate departments, as well as serve as guides to future practitioners. It is with this object that 1 venture to call the attention of the Association very briefly to the following cases: (/ASE I. — Right Femoral Hernia with Sloughing Sac and Con- tents Simulating Large Intestine. — J. W., a farmer's wife, aged 55, was admitted to tho Montreal General Hospital on the night of tho 24th of March; ir-iOO, complaining of swelling in right groin, which was causing severe constitutional disturb- ance. Tho patient was a large, fleshy woman, tho mother of eleven children, and accustomed to hard work. Her intelli- gence was of a low order, and a clear history of her illness was obtainetl with diflftculty. Tho family history was not remarkable and had no bearing on tho present illness, which began ten days before admission (March 14th, 1890), when she discovered a lump in the groin as large as a "doubled up fist." This lump was painful and tense and gradually increased in size and became rod and swollen and very tender, so that on tho 20th of March, four days before admission, she consulted a doctor, who diagnosed hernia and partially reduced it, giving her marked relief. The mass did not entirely dis- appear and the swelling continued to increase till she came to tho hospital. During all this time the bowels had been moved regulai'lj' and there had been no vomiting or other symptoms of strangulalion bej'ond tho acute local symptoms described. On admission tho })atient was in great pain and was unable to stand on account of the painful mass in the groin. Tempera- Read before the Canadian Medical Association, September 21, 1863. turo, 102" F.; pulHe, 100; ton<i;uo coatod. Tlje Hwolliiig was as lai'go as an adultV head and occupiod the region of tlio I'iglif groin und Scai-pa'H spacci. \i was of a livid red color, hard an(i induraU^d at the hasd, and fliK'tualing ov(M' (lie con- vexity — in fact, cvi<lently ii pointing abscess. On ho:ng questioned jiatient admitted that she had had a himp as hirge as a hen's egg in the groin for tlie past nine years, and tluit she had sutlbred from hahitual constipation all her life. On tlio 251 h of March, the patient having been etherized and the parts cleansed and prejjared, an incisi(Mi was made over tlio ])rominent pointing part of the tumour. About a ]Mnt of f(etid sanious pus escaped and exposed a large sloughy mass at the base. .On examination this was found to be omentum, which was removed by drawing it down and cutting through the healthy tissue, which was lirst ligatured in i^ections. Jn the centre of this, however, was found a tubular cavity ex- actly resembling the interior of the large intestine, although there was no sign of fcjceal discharge or odour from it. This tubular prolongation extended up into the abdomen as far as the finger could reach, and so closely resembled intestine that it was stitched into the skin v/ound. The distal portion which had been j-emoved was a mass of slough and threw no light upon the condition. To the outer side of the mass above referred to was found the appendix vermiformis strangulated and sloughy frOm about three-quarters of an inch below the co'cum. It was ligatured and removed and the c(L'Cum lo- turned to the abdominal cavity. The wound cavity was was packed with iodoform gauze and a sublimated gauze dressing applied. All the symptoms at once improved and the bowels moved naturally within twenty-four hours. ^Pho wound was next dressed on the fourth day and .all the sutures removed, as there was no longer any question of the integrity of the bowels. Recovery was uninterrupted and the patient was discharged on the 12th of Maj'- with the wound perfectly healed. Case II. — Congenital Oblii/e Hernia Attached to the Bottom of the Tunica Vaginalis Testis by a Hydatidiform Prolongation from the Omentum.. — F. L., aged 32, engine driver consulted me in the summer of 1889 about a right inguinal hernia, with a view to having an o])e)'ation performed lor radical cure. ''■?•;.;'' \ Tho patient, ii healthy, vigorouh and intolligont man, had sutloiod for about a year and a half from tho hoiiiia, tind had iried to retain it in poHition with trusses of a great many varieties, hut had eoinpletely failed to keep it reduced. It was small and easily reduced, but in spite of all his oll'orts it would soon come down again, pi-oducing a sickening feeling until it was again reduced. On examination I found the canal of moderate size, and considered the case an excel- lent one for treatment by truss, and so advised the patient. I suggested a i\ow form of truss and saw it properly ap- ])lied, and also took some trouble to assure myself that tho patient understood tho principles involved in this torm of treatment, lie returned to mo, however, from time lo time, protesting that it was useless for him to ti-y to go on with his work unless his hernia couid be cured by o|)eration. and tinally, on the 3rd of .lanuary, 1890, 1 had him admitted to the hospital, and on tho 11th of tho same month operated by Mcl'iWen's method, Tho hernia proved to bo omental and congenital, and tho unusual feature which ex])lained tho im- possibility of retaining it by a truss proved to bo a hydatidi- form cyst (cyst of Morgagni) growing from tho omentum and adherent to the bottom of the sac of the tunica vaginalis testis. This was just long enough to allow the hernial contents to escape within tho internal ring and yet short enough to main- tain a constant traction upon thi . portion of the omentum and bring it down in spite of any form of truss. The omental ]jroLrusion was ligatured off and removed with the cyst and tho tubular prolongation of tho tunica vaginalis dissected away from the spermatic cord and drawn up within the internal ring after McKvvon's method of dealing with the sac. The conjoined tendon was then brought over and sutured to Poupart's ligament. The patient made an excellent and un- interrupted recovery, and resumed and has continued his work as an engine driver ever since, wearing no truss or other form of support. When last soon, 21 months after operation, he declared himself perfectly well and capable of any exer- tion. This condition must be extremely rare, as I have failed, after a fairly exhaustive search into the literature of hernia, to find any similar case reported. (I have recently seen a case operated upon by a colleague in which the omentum was firmly adherent to tfi^> bottom of tho sac.) '/ 6 Case III. — Congenital Ca-cal Hernia.— H. K., agod three ycai'H, WHH admitted to ho.spitul Septomber 8tli, 1891, with right Hcrotal liornia, which was naid to have exinted from birth and to have been irrodiicii)lo. Operation foi- radical cure on the 'Jrd oi' November. On hiying open the sac (which was identical with the sac of tho tunica vaginalis testis) a thin, semiti-ansparcnt, diaphragm-like protrusion of peri- toneum, through wiiich the hernial contents conid be recogni/.od as the ciccum and ileum and which was adherent to the spermatic cord and the borders of the ring was discov- ered. It was found to be impossible to reduce the hernia, even after slitting u)) the inguinal canal, until the peritoneum was opened and retraction made upon the ileum, when it readily slipped back into its place. The superfluous tissues of the neck of the sac were dissected away and the remainder sutuied down ground the cord, the conjoined tendon brought over and sutured to Poupart's ligament, and the canal closed by suture. Recovery was uninterrupted, and the patient when last seen (September 15th last) was in perfect health, with no sign of j'oturn of the hernia. Case IV. — Jlernia of Tubercular Ooary and Tube through Inguinal Canal In Female Infant. — S. G., aged 12 months, a pale, foverish female child, was admitted to hospital Decem- ber 20th, 18U2, with a tumour in the right groin, which was thought to be an irreducible inguinal hernia. She had con- tracted whooping cough four months previously and one month afterwards the hernia appeared. Several unsuccessful attempts liad been made to reduce it under chloroform, and the tumour had trebled in size from the time of its first appearance. Tt was solid to the feel, freely moveable, dis- tinctly pediculated, and could bo traced into the inguinal canal. As far as could be made out it was at most very slightly sensitive and gave no impulse when the child cried. The bowels moved legularly, but the child was poorly nourished and fed badly. There was marked tubercular history in the mother's fumily. Omental hernia was diagnosed and opera- tion proceeded with December 21st. On exposing the mass it could be distinctly traced through the inguinal canal into the abdomen and the sac was adherent throughout. It was separated without much trduble and exposed a mass as large 1 an a Hmiill |Mjx«'on'« fj^^ ftiul covorod with ii ulistcnin^ mein- biune. It WHS rloiiily iiot omiMitiuii. iiml tor tliu mumoiit I wur* noiiplii-'.-oil ll l()i»kc'i| liko 11 Nvvolloii testicle. I inciHcd it uixl t"Uii<l ilia! it jriivo IK) ^ft)sh cliaraciei- winch would siillico foi- a (liii>iii<i>iM, lull that it waw iiiulc'i';;oiii<; cy>tic tit'^joiioni- tion. The pedicle wum well drawn out and lij^atuiod anil the rnaHH removed. Iho canal was ( losed hy Huturing the con- joined tendon to Poupiirt's ligament, and the patient maUe u rapid and. uneventful recovery. Prof. Adaini, who kindly took the Hj)ecimon in hand, domonwtrated that it conHisted of a;i ovary and fallo|)ian tube in an active condition of tubercular diseaHO, giant ccIIh and tubercle bacilli being both found in abundance. Case V. — Suppurative Inffamniation of Hernial Sac Simulat- ing Stran<iul(ition. — A. T., aged IT, a strong, rugged looking young man, was bi-ought to the hospital in the ambulance early in the morning of Febi-uary 2lHt, 1803, sutl'ering from symp- toms of strangulated hernia. On the afternoon of the 19th while skating ho had had a fall on the ice, which was immedi- ately followed by severe pain in the lower ])art of the abdomen, which soon settled itself definitely in the neighbour- hood of the loft inguinal canal. Ho was obliged to go homo and go to bed, and a physician was called who discovered a lump about as large as a hen's egg in the painful region and diagno.sed a hernia. The patient himself had not noticed the lump and asserted positively that there never was any enlargement there prior to the fall above mentioned. Pro- longed but ineffectual efforts at reduction wei-e made that evening and next day, and lato the next night Dr. Williams saw him and sent him to the hospital. On admission the tumour was as large as a small fist, discoloured, tense and tender. The abdomen was distended and tender in lower thii'd. Temperature, 100 ; pulse, 120 ; patient very rest'ess and complaining of great pain, although he had had consider- able quantities of morphia. There was constipation, but no vomiting. Operation was performed at eight o'clock in the morning. Dissecting down upon the tumour, the aac was found to bo greatly thickened and oedematous. On opening it about half an ounce of sero-pus escaped and it was seen to be occluded above. Another incision was then made into the sac 8 above tho occliiHion nnd a loop of Hninll intestine which was Hcarcoly conrttriclod Hlippiul back into tlio alxlomcn. Tho huv, was ligulurotl otl" woll within tho intornai r'lu^ and tho con- joined tendon drawn over and Hutiirod to Poupart's iigurnont. Tho [lationt inado an unintonuptod recovery and waw dis- chai'i^od on tho 2lHt of Mai'clj, exactly one month aftei* adiniHHioti. In Hpito of tlio hiwtory I thinlv tlioro c»n ho no douljt l)ut tliat this patient liad Hutt'oivcJ from hernia hofbre, tlio most, probable explanation beitii; that he had outgrown a hernia of childhood, the sac of which had become obliterated at tho external ring, and that the strain of the fall upon the ice protruded a portion of the abdominal contents into the nock of the sac, pushin*.' it furlhor down. Tho manipulations carried out for its reduction set up an inflammation in it, which rapidly wont <Jn to suppuration, posaibly through tho agency of the ajnacba coli.