An unusual method

At the 1887 Annual Meeting of the British Medical Association a surgeon from Sunderland, James Murphy, walked on stage brandishing a testicle. It was an arresting entrance, but no gimmick: he had a highly unusual story to tell. It concerned a patient who (for reasons which were not entirely clear) had decided to cut himself open rather than leave the job to a surgeon:

Cure of hernia performed by an unusual method

On April 12th, my friend, Dr Collie, of Sunderland, sent me word to come at once and help him with a case of strangulated hernia.

A hernia occurs when a portion of the bowel protrudes through a weakness in the abdominal wall. It may become strangulated if its blood supply becomes obstructed (for instance, by twisting or kinking of the intestine). This is a medical emergency, since the affected portion of bowel may rapidly die and become gangrenous.

On arriving at the house, I found the patient, a man, aged 58, had suffered from a reducible inguinal hernia for sixteen years.

An inguinal hernia is one in the groin. A ‘reducible’ hernia is one in which the abdominal contents may be returned to their proper position by simple pressure – and if necessary kept there by a truss or bandage.

inguinal hernia
Contemporary engraving of a small inguinal hernia

From time to time he had worn a truss, and when the hernia descended he could always get it back again, until the previous night, when he failed to return it, and suffered a good deal of pain in it; had vomiting, and, in short, all the symptoms of strangulated hernia.

As already mentioned, an emergency, and one that may be imminently fatal unless promptly treated.

Failing to reduce it, and having read that surgeons under such circumstances cut for hernia, he got up, took a razor, and proceeded to do so, and cut freely, cutting right through the sac, cutting off these two large pieces of omentum that I show you, and almost cutting completely through his right spermatic cord.

This is not recommended (in case you were thinking of following suit). The omentum is an apron of tissue that ordinarily sits in front of the abdominal organs. A competent surgeon of this period would have made a much less dramatic incision – just enough to expose the affected portion of the intestine, and gently return it to its proper place. A few strategically-placed sutures might also be made in the hope of preventing any recurrence. This patient’s attempt was – not to put too fine a point on it – cack-handed.

Luckily, there was no intestine in the sac.

This was lucky indeed. If there had been any intestine in the sac he would have cut through it, allowing gut contents to escape into the abdominal cavity – an almost certain recipe for widespread infection.

When I saw him he was almost pulseless, and completely blanched, so free had been the flow of blood from the artery in the divided cord, which was almost the only place from which haemorrhage occurred. The remaining piece of omentum that protruded through the opening had a few bleeding points, and these were secured with catgut, and the stump was easily returned through the ring.

As it turned out, the surgeon was able to put make good this botched job without too much difficulty.

The testicle was removed from the scrotum, and as the sac was already cut completely through, I performed the remaining steps of the method of Dr Mitchell Banks for the radical cure of hernia and finally closed the wound, the whole being done antiseptically.

Sir William Mitchell Banks was an important Scottish surgeon who is today best known as the first to advocate radical mastectomy to treat breast cancer – removing not just the breast itself, but the lymph nodes in the armpit, to which malignant cells often spread.

Banks also devised new surgical techniques for the treatment of hernia – made possible by the recent innovations of Joseph Lister, whose use of ‘antiseptic’ methods had made the operating theatre a far cleaner, and therefore safer, environment.

Under the skilful care of Dr Collie, the man recovered perfectly; but, having become insane – which he doubtless was at the time of the operation – he had to be removed to the workhouse, and Dr Nursey informs me so far there has been no return of the hernia.

A bittersweet conclusion: the patient had been saved from death by strangulated hernia, but his mental state was apparently incurable. The author concludes by observing that

The removed portions of the omentum and the testicle were exhibited to the meeting.

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