Intraperitoneal Hernia. A Case.

BY WILLIAM L. WALLACE, M.D. and JAMES S. ALLEN, M.D.
Syracuse, N. Y.

Mr. S., aged 35, a chauffeur, came to the office March 10, 1910, complaining of recurrent attacks of severe pain in the right side of his abdomen. Family and personal history negative. He had always been well up to four or five years ago, since which time he had had severe attacks of cramp-like pains which had come suddenly, at times when running his car, and had been severe enough to force him to leave the machine and lie doubled up at the roadside. Each attack of pain had subsided very gradually. For the last year he had vomited his breakfast nearly every morning; but he had not vomited during the attacks except once or twice. He had been very constipated, requiring large amounts of cathartic medicines, but there had been no blood or mucus in the stools.

Examination showed a well nourished man with abdomen slightly rigid and considerable tenderness on the right side just above McBurney's point. Rectal examination was negative. Exploration of gall bladder and appendix was advised.

The patient was operated at Good Shepherd Hospital, Syracuse, N. Y., March 17, 1910. A small incision was made through the outer border of the right rectus. The gall bladder and ducts were normal. The appendix was slightly inflamed and was removed. Then, thinking that enough had not been found to account for the severe pains, it was decided to make further search. Meckel's diverticular trouble was thought of, and investigation of the ileum from the ileocecal valve was begun. About three inches from the valve the intestine seemed to run into a large mass and be lost. The incision was enlarged. Then presented in the wound what appeared to be another layer of peritoneum with coils of intestine showing behind. At once retroperitoneal hernia was thought of, and examination showed that all the small intestines except the first and last three inches, with the entire mesentery, were contained in a hernial sac.

The intestines passed behind a band in the free border of a fold which formed an inferior duodenal fossa, and then pushed anteriorly, distending the double layer of the inferior duodenal fold to form a sac which filled the peritoneal cavity. The sac hung loosely, connected with the posterior abdominal wall by a comparatively narrow neck or pedicle, having a mouth above and to the left which was a little larger than a silver dollar. The intestines were carefully withdrawn and when the sac was half emptied, the mass was delivered outside the abdomen. Fig. 1. The remainder of the intestines now having been withdrawn, the collapsed sac, which was then about six inches long, hung from the posterior abdominal wall just below the duodeno-jejunal flexure. The band in the neck of the sac contained no blood

vessels of any size, and the sac which was formed by a double layer of peritoneum was tied off and removed. The wound was closed without drainage. Three weeks later he had recovered and left the hospital.

Be

Internal abdominal hernia are usually retroperitoneal. ginning in a preexisting fossa, a knuckle of gut dissects up the posterior parietal peritoneum with the mesenteric bloodvessels. Such a condition is found most frequently in the duodeno-jejunal region. The duodenum, it will be remembered, comes forward. as the jejunum from beneath the transverse mesocolon, after

passing under the superior mesenteric artery. If we pull the jejunum to the right as in Fig. 2, the small gut is actually hooked around the superior mesenteric vessels, with the duodenum behind and the jejunum in front of the duodeno-jejunal angle at the left. Thus the duodeno-jejunal region is in a natural fossa

with the superior mesenteric vessels at the right and the inferior at the left. The number of minor fossæ in this region may be indefinitely multiplied, according to the folds and adhesions, Moynihan describing nine. Three forms of hernia are usual. A right duodenal hernia is formed when the gut pushes a sac to the right under the arch of the superior mesenteric vessels. A left duodenal hernia is formed when the gut pushes a sac of peritoneum to the left under the inferior mesenteric vessels. If the gut pushes a sac under the left colic artery into the transverse mesocolon, a so-called mesenteric hernia is formed.

The inferior duodenal fossa looks upward and toward the left with the blind end downward and toward the right. The margin of the double fold of peritoneum forming the fossa is usually bounded by a comparatively thick fibrous non-vascular band. A hernia into this fossa if it dissected to the left or right would be a left or right retroperitoneal hernia; if it distended the inferior duodenal fold into a sac coming out into the free peritoneal cavity between the bloodvessels, it would not be retroperitoneal, but intraperitoneal, as was this case.

In ten autopsies

Inferior duodenal fossæ are very common. performed during the last few weeks the inferior duodenal fossa was found nine times.

1000 E. GENESEE STREET.

TH

Chronic Gonorrhea in the Female.

[The Hospital, November 5, 1910.]

HAT chronic gonorrhea is far less uncommon in the female than one might suppose from the accounts given in the textbooks is being made increasingly obvious by modern publications upon the subject; and seeing that even a slight gleet on the part of the husband may lead to recurrent infection of the wife, and thus to chronic gonorrhea, without there having been any definite acute gonorrhea, it is not surprising that the chronic form of the disease is not uncommon in females.

A NOTE ON TREATMENT.

In regard to its treatment, if there are active symptoms the patient should be kept absolutely in bed for the time being. Coitus must be forbidden, and if the husband shows any signs of the disease he must be treated for it actively either by the use of intraurethral injections or by means of vaccines, or by both. The diagnosis having been confirmed by a thorough examination, and, if possible, by the detection of the gonococcus in films from any of the infected parts, gonococcal vaccine treatment should be adopted in the woman also; but rather than rely upon vaccines only the action of the latter should be assisted in every possible way besides. The diet should be bland but generous, bland in kind but generous in amount, including plenty of proteid, especially in the form of milk. It is inadvisable to use the curet except in special conditions, and medical treatment will often suffice without operative measures.

MECHANICAL AND ANTISEPTIC CLEANSING.

Dr. Lochrane advises that the vulva should first be cleaned thoroughly by washing with soap and water and then with a

solution of biniodide or perchloride of mercury, a vaginal douche of biniodide of mercury solution, 1 in 4,000, given daily for four days. Bartholin's glands are generally involved, and their ducts. should be swabbed each day with some antiseptic such as a 20 per cent. solution of argyrol on sterilised cottonwool and a probe. In resistant cases it may be necessary to lay open the ducts of these glands and pack them with gauze soaked in a 5 per cent. solution of argyrol. The cervix uteri must be exposed, the cervical canal swabbed free from discharge, any Nabothian follicles present should be laid open, and any erosion should be treated with some astringent antiseptic such as a 20 per cent. solution of picric acid in alcohol. The mucous membrane of the cervical canal as far as the internal os is then thoroughly swabbed with a solution of 20 per cent. of argyrol, which has the advantage over other preparations of being relatively soluble, highly bactericidal, and non-irritating.

DOUCHING AND CURETING.

Lochrane advises that any excess of solution should be wiped away and a small pencil-shaped piece of fresh bakers' yeast inserted into the mouth of the cervical canal, a few grains of ordinary, cane sugar being inserted after it. The yeast grows upon the sugar and has a remarkable destructive effect upon the gonococcus and other pyogenic cocci. A large piece of fresh yeast with a little cane sugar may be left against the cervix. This treatment may be repeated every day for seven days and then stopped, the discharge being re-examined for gonococci. If the disease has not reached the endometrium the condition may be entirely cured by the above measures, and in any case it is important not to dilate the internal os or to pass anything upward beyond it lest the disease should be spread to the interior of the uterus. If, however, the interior of the uterus has already become involved before the patient comes under treatment, it may be necessary to dilate the cervical canal and swab out the interior of the uterus likewise with argyrol solution, beginning with half the strength used in the cervical canal, but gradually increasing until even 20 per cent. may be reached, provided no increase is produced in the endometritis. Curetting of the interior of the uterus and cervical canal should only be resorted to if prolonged rest, diet and treatment as above by argyrol, yeast, and sugar do not result in cessation of the profuse discharge and heavy loss at the monthly periods. There is always some risk of extending the disease if the measures adopted are too active. If relief has been partial only, it is better to wait for a month or more, seeing the patient at intervals, because it not infrequently happens that when the active measures have brought some relief the cure con