On August 18, 1871, my friend Mr. Kelson Wright, of Kennington, asked me to see with him a case of strangulated hernia in an old, half-childish man, aged 71. He had been the subject of a right scrotal hernia for thirty years, and had worn a truss. He had had occasional difficulty in its reduction after its descent; but Mr. Wright had always succeeded in reducing it.
An unpleasant complaint, and one which could only be managed, rather than cured, at this date. Hernias occur when part of the gut protrudes through a weakness in the abdominal wall, usually with just a covering of skin and subcutaneous fat. These sometimes cause no symptoms beyond discomfort and an unsightly swelling, but a ‘strangulated’ hernia is one in which the blood supply to part of the intestines is cut off. This can be dangerous as the affected section of the gut may die, eventually causing gangrene, infection and death. In this example the lower part of the intestine had fallen into the scrotal sac. ‘Reducing’ a hernia is the act of pushing the gut back into its normal position; it may then be kept in place with a truss.
On the present occasion the same effort had failed, and when I saw him vomiting had existed for two days, and a large hernia existed in the right side of the scrotum; one portion of it felt tenser than the other. Chloroform was given, and the taxis employed, but without success; consequently herniotomy was performed, it being necessary to expose the bowel.
Taxis is simply the act of reduction – pushing the intestine back. Herniotomy means opening the hernia; in this case, cutting open the scrotum. At least he had chloroform: thirty years earlier this operation would have been even more unpleasant.
When this was done the caecum escaped, dragging down with it some three inches of small intestine covered with peritoneum—the external ring pressing firmly upon it.
The caecum (usually spelt ‘cecum’ today) is a pouch at the top end of the large intestine. The peritoneum is the membrane that covers the gut.
With some difficulty the bowel was returned, the wound brought together, and the whole carefully bound together by means of a pad and spica bandage of strapping. A morphia suppository was given. During the night, however, this old man would get out of bed, and in the attempt he tore off all the dressings.
As a consequence, the bowel came down again; vomiting returned, with abdominal pain. Mr. Wright was sent for, but all this efforts to return the intestine were fruitless. I was consequently sent for. I found the old man lower than when I saw him before. The hernia was down larger than ever. I gave him chloroform, and attempted reduction, but failed.
The surgeon then enlarged the aperture through which the gut had fallen, hoping to make it easier to reduce the hernia, but all that happened was that more of the large intestine dropped down. Things were getting serious.
I consequently punctured the intestine in four or five places with a grooved needle, and let off the wind; this measure enabling me to do what, under other circumstances, I could not do—reduce the hernia. The wound was then readjusted, and a good pad firmly secured on with strapping, opium being given; and I am pleased to add, no one bad symptom followed these rough measures, and a good recovery ensued.
Pretty remarkable. This was a daring effort at this date – puncturing the intestine to release gas would have been frowned upon by many of his peers. Numerous things might have gone wrong: bleeding from the wound in the intestines, infection or gut contents might have leaked into the abdominal cavity, causing peritonitis. Amazingly, none of these occurred.
Mr. Wright tells me the wound united without a drop of pus appearing, the whole uniting by primary union. It was interesting to note that when the bowel was punctured nothing but wind escaped, except in one spot, where the smallest drop of blood oozed out evidently from the congested intestinal walls. None of the contents of the intestines escaped even after the rough manipulation to which they were subjected.
Both surgeon and patient had a lucky escape.