Two cases of hernia, both treated by laparotomy : I. A properitoneal hernia. II. A femoral Littré's hernia / by W.W. Keen.

  • Keen, William W. (William Williams), 1837-1932.
Date:
[1892]
Catalogue details

Licence: Public Domain Mark

Credit: Two cases of hernia, both treated by laparotomy : I. A properitoneal hernia. II. A femoral Littré's hernia / by W.W. Keen. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    W. W. KEEX, M.D., ON but on pushing them up in a direction parallel to Poupart's ligament, they entered what was supposed to be the abdominal cavity. I noticed, however, that the moment the finger was removed the bowel especially came down into the canal again. It would not stay reduced, and it had lost nothing of its dark color. I now continued the incision in the sac completely up to the internal ring, and passed my finger into e supposed abdominal cavity for the purpose of investigating the reason for this persistent reproduction of the hernia. I found a large smooth cavity lying in the iliac fossa and extending outward to about the anterior superior spine of the ilium. Omentum was readily felt lying in its interior. Exploring its wall systematically, I found a number of adhesions between the omentum and its wall, but the bowel was free from adhesions. As the finger passed around the wall and approached the position of the internal ring, I suddenly became aware of an opening corresponding to the posi- tion of the ring. It admitted only the point of.my finger, but on gently forcing in the whole finger I found that it was then really in the abdominal cavity. The pouch which I first supposed to be the peritoneal cavity was really extra-peritoneal. Evi- dently, then, I had to deal with an inguinal preperitoneal hernia. I found that the bowel and omentum protruded through the ring, and that this was the seat of the con- striction. I now drew out all the collapsed bowel which lay in the preperitoneal sac, and with two fingers stretched the internal ring with ease. I was then able to draw down the gut until I could see the seat of the constriction of the bowel. There were fifteen inches of bowel in the sac, and the narrow constriction was very marked. The gut dilated to about half its calibre so soon as the constriction was removed. I had now no difficulty in reducing both omentum and bowel into the true peritoneal cavity. The condition of the patient was very poor: his respiration was hurried and shallow, and the lividity of his lips made me anxious to terminate the operation as soon as possible; so I did McBurney's operation for radical cure. During the opera- tion,- which lasted about three-quarters of an hour, he had been surrounded by bot- tles of hot water, and brandy had been administered hypodermatically a number of times. He recovered consciousness quickly, but gradually sank from exhaustion, and died at 2 a.m., eight hours after the operation. No autopsy could by any possibility be obtained. Remarks.—This case presents another illustration of the fact that a preperitoneal hernia is almost never diagnosticated before operation. Had it not been that the bowel persistently returned after its apparent reduction, I should almost certainly have overlooked the preperitoneal sac, and the condition would have been entirely unrelieved. His death was evidently the result of the marked shock from which he was suffering by reason of the obstruction. FEMORAL LITTRE'S HERNIA TREATED BY LAPAROTOMY; RE- COVERY. Case II.—Mrs. Y., aged sixty, of Newark, Delaware, was seen by me, at the request of Dr. Henry, June 7, 1891. Three days previously she had been seized with severe colicky pains, which Dr. Henry relieved by morphine followed by purga- tives and later by enemata. The lower bowel was emptied of scybalous masses, after which no movement took place. She vomited almost constantly from the beginning of the attack, and by the morning of the 7th this had assumed a faecal character. There had been no pain of any moment after the initial colic. I found a spare but well-nourished woman, who before the present sickness had never been ill in her life. There was evident faecal vomiting, slight pain referred to the region of the umbilicus, and obstinate constipation. Examination by the vagina and