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A CASE OF C/FXAL HERNIA. 
 
 symptoms of stran(.ulat10n ; herniotomy; wound of the 
 bowel; suture; recovery.' 
 
 By FRANCIS J. SHEPHERD, M. D., C. M., 
 
 of MONTREAL. 
 
 I'KOI'KSSOK Ol- ANATOMY AND LECTUREK ON Ol'ERATIX 1-: SURCERY IN M'dll.L 
 I NIVERSITV ; SlRdEoN TO THE MONTRKAI- tlENRRAL HOSPITAL. 
 
 CASES of cecal hernia are .sufficiently rare to be of 
 interest, many surgeons having pa.ssed through a long 
 course of hospital practice without ever having .seen a case of 
 cecal hernia. It is seen more commonly in children and is 
 usually of congenital origin, being covered completely by perito- 
 neum and lying in its own sac. In other ca.ses, especially where 
 the hernia is "of the acquired form, it follows a pre-exi.sting 
 enterocele, the sac of which enlarging and growing downwards, 
 tears away the peritoneum from the iliac fossa, and later, if the 
 enlargement continues, partially deprives the cecum itself of its 
 peritoneal covering at the same time disjjlacing and drawing 
 down a portion of it. Such was the course of events, I imagine, 
 in the case I am about to relate. These ca.ses cannot be readily 
 diagnosed before operation, and to the surgeon they offer great 
 difficulties in operating for the radical cure. They arc not ea.sy 
 of reduction and are often of large sijx. 
 
 Case. H. H., aet., 53, door-porter, was admitted into the 
 wards of the Montreal General Hospital, on April 18, 1891, suf- 
 fering from strangulated inguinal hernia. 
 
 History, Has been a soldier. For the last eleven years 
 lias had a right inguinal hernia, for which he has from time to 
 time worn a truss. Occasionally the hernia comes down, but he 
 has always been able to return it. Two years ago, whilst lifting 
 
 'Read before the meeting of the Canadian Medical Association,' held in 
 Montreal, St-ptcniber 16, 1891. 
 
FRANCIS J. SHEPHERD 
 
 a heavy weight, the hernia came down and was reduced with 
 difficulty. A hard lump has remained in the inguinal canal 
 ever since. 
 
 Three days ago the hernia came down and he could not 
 return it. He went to his work as usual, but suffered consider- 
 able pain. He was constipated, but had no vomiting. The pain 
 increased and the tumor became excessively tender. Constipa- 
 tion was marked and there was great nausea and loss of appetite. 
 He had no severe vomiting. His condition not improving he 
 was sent to the hospital for relief. 
 
 On entrance the following notes were made : A strong, 
 healthy-looking but spare man, aet. 53, but looks older. Has an 
 expression of great suffering in his face, and complains of nausea 
 and of great pain in right groin. On examination a sausage- 
 shaped swelling is found at the site of the right inguinal canal, 
 which is hard, tense, nodular, dull on percussion, and exces- 
 sively tender. There is no impulse on coughing. 
 
 Below and continuous with this swelling and filling up the 
 scrotum is a much softer tumor, which is neither tense nor 
 tender. The man was immediately placed under ether and 
 gentle taxis was employed, but without avail, so the operation of 
 herniotomy was at once proceeded with. 
 
 Operation. The parts having been properly cleaned and 
 shaven, an incision was made over the sausage-shaped swelling, 
 and after cutting through the skin a dense, hard mass was met 
 with, which appeared to be composed of fibrous tissue. On 
 extending the incision below this mass the thin, bluish wall of a 
 sac was discovered. This was incised and immediately about 
 two ounces of a straw-colored fluid escaped. No intestine was 
 found in this sac and it was supposed that the gut slipped back 
 as the fluid was evacuated. The sac was now slit up to the 
 upper end, through the thickene t fibrous mass, and then an 
 attempt was made to dissect it out. This was found to be a 
 most difficult task, as it was very adherent. The floor of the sac 
 was composed of an irregular cystic mass, with elevated ridges 
 containing large blood-vessels. This mass, on close examination, 
 proved to be omentum which had become incorporated with the 
 posterior wall of the sac. Posteriorly the sac was so intimately 
 blended with the spermatic cord that separation could not be 
 
 'ti »■ 
 
C^CAL HERNIA. 
 
 effected without destroying the vas deferens. So the cord was 
 cut through and the testicle afterwares excised. The veins of 
 the cord were enormously distended and the whole cord was in 
 a state of cystic degeneration, which formed a mass below the 
 hernial sac, causing the second swelling already alluded to. 
 After a time I managed to separate the sac and the structures 
 incorporated with it. The neck, which seemed to be thicker 
 than usual, was freed beyond the internal ring, pulled down 
 and then tied with strong silk. It was now turned up and 
 scissors were used to cut it off. The first cut made from below, 
 much to my surprise, opened into bowel. The ligature was 
 immediately loosened and it was new found that the cut had 
 been made into a collapsed portion of caecum which was closely 
 attached to the upper part of the posterior wall of the sac. On 
 pulling this down further the appendix was seen. The cut in 
 the bowel was about one and a half inches long and the part 
 of caecum opened was quite free from faeces. It, however, was 
 well washed and then the cut was closed with a continuous 
 suture of fine silk and a Lembert suture over this again. The 
 omentum was separated from the sac, tied off and returned. 
 The sac itself was ligatured below its attachment to the cacum 
 and the part in front cut away and then returned within the 
 abdomen with the sutured caecum. A radical cure was now 
 performed by suturing the conjoined tendon to Poupa;1:'s liga- 
 ment. The wound was sutured with silk-worm ^; I and a 
 drain placed at the lower end. 
 
 The patient's condition was excellent at the end of this pro- 
 longed operation, and he had no vomiting afterwards. Next day 
 his temperature and pulse were normal, there was some pain 
 about the wound, but his condition was still excellent. On April 
 25th, six days after the operation, the wound was dressed, the 
 tube removed and stitches taken out. There was union every- 
 where by first intention. He went on well, without a bad 
 symptom, and was discharged from the hospital on the i6th of 
 May with a small sinus persisting where the drainage-tube had 
 been. He returned to the hospital on May 22d, saying he felt 
 well and was attending to his work as usual. Had some pain 
 and tenderness about centre of scar. June 5th, returned again, 
 with a small suppurating point at (.entre of scar, through which 
 
FA\l.yC/S /. SH/lPllEKl). 
 
 protruded a silk ligature. This proved to be one of the ligatures 
 which united the conjoined tendon to Poupart's ligament. The 
 sinus now quickly healed and the patient has felt well ever since, 
 attending to his duties and suffering no pain. He has never 
 worn a truss. In this case there was no doubt a double hernia, 
 viz., one of the c.iecum and one of the small intestines in front 
 of the caecum. The hernial sac, which contained the small intes- 
 tines and omentum, had for its posterior wall the layer of perito- 
 neum covering the caecum, and as it descended it pulled the 
 caecum down with it. From prolonged use of a truss and inflam- 
 matory attacks which had occasionally occurred the sac was 
 thickened and the omentum so fused with ii. that it really had 
 become part of the sac. Closely incorporated with the posterior 
 wall of the sac was the lower end of the caecum, which was only 
 covered in front by peritoneum, and as it was empty and the 
 same color as the sac, from having been herniated, probably for 
 some years, it was not recognized or even suspected, until, when 
 cutting off the sac, it was opened. As soon as this occurred the 
 cut bowel was pulled down and then it was recognized as the 
 caecum, and the character of the hernia was at once apparent. 
 The cut in the bowel was immediately sutured and no harm 
 resulted. The removal of the right testicle was a necessary pro- 
 ceeding, for the cord and sac were so blended that a separation 
 without injury was not possible. In one way the sacrifice of the 
 testicle was a great gain, in that it helped to make the radical 
 cure more certain, an additional plug in the canal being provided 
 by the stump of the cord.