AN INTERESTING CASE OF SCROTAL HERNIA.
By G. E. Bennett, '09.
Senior Medical Student.
Patient—George Kolubaher.
Age—Sixty-six years.
Occupation—At present a farmer; formerly worked as laborer in stone quarry.
Complaint—Patient entered the hospital on January 21, 1909, complaining of great pain and discomfort in the right inguinal region and in the scrotum of the same side.
Physical Examination—Inspection showed an enormously enlarged scrotum, more marked on the right side, and a prominent swelling along the right inguinal canal, which was most marked when standing. Marked discoloration on the skin of the scrotum and inner side of both thighs, probably due to use of counter-irritants.
Palpation—Mass soft and freely movable, showing no skin attachments; slight impulse on coughing. Slightly painful on pressure. Some gurgling when manipulated.
Percussion—Slightly tympanitic.
Remarks—Contents of the sacs were forced into abdominal cavity after prolonged manipulation, returning to original condition as soon as pressure was taken away.
History of patient shows nothing of interest except that of the present condition, which began suddenly twenty years ago. While lifting a heavy block of stone had a feeling as though something had “given away” in his right side. This sensation was immediately followed by one of intense pain and general discomfort. The day following the patient noticed a small lump in the right inguinal region that disappeared on pressure, returning when he lifted any heavy object.
For eighteen years the condition gave him no serious discomfort except for the wearing of a truss and becoming larger. Two years ago the truss was discarded as being useless.
One week ago conditions grew suddenly worse, and patient was confined to bed. Has suffered a great deal of pain and has been unable to sleep.
On January 22, 1909, patient was operated upon by Professor Winslow. Operation as follows:
Patient was brought to the operating room at 11.30 A. M., anesthetized and prepared for an aseptic operation.
Incision about five inches in length was made parallel to Poupart's ligament and immediately over the inguinal canal, passing through the skin and subcutaneous fat. The external ring having been exposed a grooved director was passed into same, passing under the aponeurosis of the external oblique muscle; fibers of same were split, using the director as a protective guide. The sac was exposed and carefully dissected free from its surrounding tissues, and upon examination was found to be continuous with the covering of the testacle (giving the appearance of a congenital hernia). The sac was next opened and found to contain small intestines and a Meckel's diverticulum. Following this the intestines were replaced in the abdominal cavity. Digital examination through the internal ring showed the bladder to be adherent to the peritoneum at the margin and toward the median line. The sac was tied close to the internal ring, cut free. The distal portions of the sac were drawn upward, bringing the testacle into view; sac was cut close to same and sutured so as to enclose the greater part of it.
The margins of the internal oblique and transversalis muscles were sutured to Poupart's ligament by a mattress suture. The aponeurosis of the external oblique was re-established into normal position by suturing, and the skin closed by subcutaneous silver wire suture silk having been used for all other sutures.
Sterile dressings were then applied and cardboard splints to keep limb immobile. Then bandaged with crenolin. The patient left the operating room at 1 P. M. in good condition.
Notes of Interest—
That a hernia, apparently congenital, should not have made an earlier appearance.
The presence of a Meckel's diverticulum in the sac, this being the condition that gives rise to a true Richter's hernia.
That a hernia of so large proportion should have caused so little trouble to the patient.
Patient recovered in very short time, leaving the hospital in good condition.