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1.-Abdominal peritoneum beyond the first incision which divided the internal

ring.

IV.-Valve.

V. Cut ends of the Internal ring.

nate this rare form of hernia. Among these, 'interstitial' is perhaps the most often seen and the most appropriate." The authors then discuss at considerable length etiology, diagnosis, and treatment; and picture several cases of hernia which they call properitoneal hernia, but make no distinction between the variety behind the muscle and the one between or in front of the muscle.

The main difference between the properitoneal hernia and the interstitial is an anatomical one, in that more or less of the muscle lies behind in the interstitial variety, while none is behind in the properitoneal. The main difference in the symptoms is the presence of a tumor, whenever the hernia is down, in the interstitial variety; while in the properitoneal the intestine may be down and strangulated, and yet no tumor. The importance of recognizing the variety as properitoneal lies in the fact that the hernia may be entirely overlooked, even at the time of an operation. The intestine, which has apparently been reduced without any special trouble, is still constricted at the internal ring, and the strangulation still unrelieved.

The term "properitoneal hernia" is a modern one, and an exact knowledge of the pathology of the condition implied dates but a few years back; but its most prominent signs and best method of treatment were described a century or more ago.

Gross Surgery of 1860, under "Reduction in mass," has an excellent pen-picture of a properitoneal hernia; and no better set of rules can be laid down to-day for detecting the presence of the difficulty or for dealing with it when present than is to be found on page 795 where the author says:

“An examination of the parts of hernia will usually enable the surgeon to recognize the nature of the accident; he will ascertain that a tumor had previously existed, and will learn, from a description of its general characters and the symptoms occasioned by it. that it was in all probability a strangulated rupture. He will then find, on examining the part, that there is total absence of all that fulness which is occasioned by the presence of the sac, even after its contents only have been reduced; the sac, in such cases, always giving rise to a feeling of fulness and roundness in the part. He will, on the contrary, find that the abdominal ring is peculiarly and very distinctly opened; it is much larger than usual, and somewhat rounded. On pushing the finger into the canal, this will be felt quite empty, but in some cases on deep pressure with the finger,

especially when the patient stands up or coughs, a rounded tumor may be indistinctly felt behind the ordinary seat of the hernia. In many cases, however, the most careful manual examination will fail to detect any prominence of this kind.

"If, after careful examination of such a case as this, in which the symptoms of strangulation continue, the surgeon learns by the previous history that a tumor has existed, that it has suddenly gone up, and, further, if he finds that the seat of the supposed hernia presents the negative evidence that has just been described, it will then be necessary for him to push his inquiries a step further by an exploratory incision."

While in Vienna I had the opportunity to examine a properitoneal hernia which had been operated upon; the true condition had not been recognized, so the obstruction was not relieved. The case terminated fatally and I was struck by the fact that a small ring of peritoneum, which is usually so dilatable and gives way before a slight pressure, yet may, if the conditions are right, prove most disastrous. How is this possible? The method in which the intestines make pressure upon the abdominal walls is very analagous to the force of water as exerted upon surrounding substances. How easily is a portion of the water separated from the rest! How readily does a stone sink into the depths! But what a mighty force is exerted when tossed by the wild and boisterous wind; or, when diverted to man's use, it turns the wheels in a thousand mills! So with the intestine, a single loop is easily lifted and moved, seemingly it has no strength of its own, and only the abdominal surgeon can appreciate the difficulty of insinuating the hand between the intestines to the posterior wall! Thus, in the formation of hernia, it is not the strength of a single loop that is brought to bear upon the internal wall, but the entire intraabdominal force. After the internal ring is passed, the power necessary to produce strangulation need not be great enough to oppose the intra-abdominal pressure, but only sufficient to control one loop; so the return blood supply is cut off by only a slight constriction. Thus is the slight fold of peritoneum which forms. the internal ring able to bring about such disastrous results.

I have here the specimen from a marked case of properitoneal hernia, the main features of which are as follows:

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J. McC. had, when a baby, a left inguinal hernia; it apparently healed and gave him no trouble until seven years ago, when it returned, and has since been kept in place with great difficulty by means of a truss. He is now thirty-three years old, and enjoys good health in every other respect The hernia annoys him by coming down at the slightest exertion and is then very difficult to reduce; it can only be done by assuming the recumbent posture. Several times he has had to take an anesthetic to get it reduced. He is a collector by trade, and May 5th, while in one of the suburbs of the city, his hernia came down; the pain and nausea indicated that it was more than an ordinary attack; he was carried into a drug store and the neighboring doctor and dentist were called in. After a futile attempt at reduction, an anesthetic was given and the hernia apparently reduced. Before he had fully recovered from the anesthetic a slight attack of vomiting brought out the hernia, as big as ever. Another effort was made at reduction without the anesthetic, but he was unable to stand the pain of the manipulation; this made the doctor and dentist so mad they kicked him out of the store, saying they would have nothing to do with such a baby. He finally succeeded in getting a carriage to carry him home, vomiting several times on the way. My friend, Dr. Aldrich, was called at 5 o'clock, May 6th. He advised immediate operation for strangulated hernia, and had him removed to the hospital, where I saw him. By this time the bowels were somewhat tympanitic and the vomiting had become stercora

ceous.

Operation. An incision over the external abdominal ring revealed an edematous sac; in this sac was found eighteen inches of very dark intestines, as well as an ounce of straw-colored serum. The internal ring was incised and the intestine reduced through the external ring with considerable difficulty. At this time the site of the operation looked as if it were ready for the final occluding stitches, and I can readily see how the condition might be overlooked, and has been overlooked, notwithstanding the fact that the symptoms of strangulation were not relieved after the opera

tion.

As I endeavored to pass the finger through the internal

ring, as is my custom, to see if everything was in order, the intestines were found to be immediately beneath the external ring; the slightest traction on the presenting loop sufficed to bring the

1

.

- whole eighteen inches external again; it was a second time reduced with difficulty; the results, however, were no better. On making a careful examination it was found that at the neck of the sac at the internal ring was a valve, half an inch, which deflected the intestine into a diverticulum of the sac; this lesser compartment extended downwards between the pelvic wall and the pelvic peritoneum. It was only by placing a retractor through the internal ring and making strong traction upwards, while at the same time a second retractor held down the valve, that the intestine was reduced into the abdominal cavity. It thus became plain why on former occasions he had so much difficulty. The operation was completed after a modified Australian or O'Hara method, silver wire being used instead of the material of the original operation. Union was by first intention. At the time of the operation the bladder was not seen, but after the operation there was considerable bladder irritation and on the eighth day there was complete retention. I was not able to enter the bladder with any instrument, but overcame the retention by applying poultices to the abdomen and perineum. Convalescence otherwise uneventful.

To conclude, this case emphasizes the necessity of bearing in mind the possibility of properitoneal hernia in all cases that are difficult of reduction. At the time of operation, after the intestine. has apparently been reduced, the finger should be passed through the internal ring into the abdomen, to be sure that the intestine has been reduced into the abdomen and not into a second sac.

Lastly, it is the desire of the reporter again to call attention to the desirability of restricting the term "properitoneal hernia" to those cases in which a part or all of the sac is between the muscle and the peritoneum.

SITUS VISCERUM TRANSVERSUS.

BY T. L. CHADBOURNE, B. S., M. D.,

Instructor in Physical Diagnosis, Ohio Medical University.

Although this anomaly is not so rare as it was formerly thought to be, still cases where the diagnosis has been made intra vitam are uncommon enough to be of interest. Altogether about 200 cases have been reported in literature, in a large part of these the condition having been first discovered at autopsy. Since 1894

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