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STRANGULATED FEMORAL HERNIA,
GAS
ATTENDED WITH SOME UNUSUAL CIRCUMSTANCES.
01
By THOMAS CHEVALIER, Esq. F.L.S.
25
SURGEON EXTRAORDINARY TO THE PRINCE REGENT, AND SURGEON TO
THE WESTMINSTER GENERAL DISPENSARY.
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Read May 25, 1813.
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CASE I.
Se TOD BE
ON the 2d of July, 1806, I was desired to visit
Catherine Lewis, who was supposed to have la-
boured under enteritis for seven days. But as the
medicines employed had produced no beneficial
effect, and considerable tension of the abdomen
had come on, it was thought that surgical assist-
ance might be required.
rollen
S
On examination, I found a tumour as large as a
middle-sized walnut, under Poupart's ligament, on
the left thigh. It was remarkably firm; but as,
from its form and extent towards the abdomen, I
had not the smallest doubt of its being a hernia,
proceeded to the operation without delay. On
a

326
Two CASES OF STRANGULATED
dividing the integuments, the tumour presented the
appearance of a cluster of indurated absorbent
glands, and of these, indeed, it was externally
composed. I divided it by the most cautious dis-
section; and, after cutting through a mass half an
inch in thickness, found I had made an opening
into a cavity, which I enlarged as far as the external
protrusion extended. Not a drop of fluid was dis-
charged, and I could only just discover a small
portion of strangulated intestine. I found this
glandular cortex of the sac (if I may so call it)
to be continued under Poupart's ligament, and it
was not until I had divided the whole of this liga-
ment by gradual dissection, from without, that I
could obtain a satisfactory view of the protruded
gut. I found it, however, so fast impacted in its
rigid covering, that even then it was impossible to .
reduce it by any moderate pressure. It is neces-
sary,
however, here to remark, that as the incision
through Poupart's ligament was made from with-
out, the mouth of the sac was as yet undivided.
I therefore introduced a director, and with a blunt-
pointed bistoury divided the mouth of the sac to-
wards the symphysis pubis, after which the intest-
ine was easily returned. But the immediate gush
of several pints of purulent fluid, mixed with fæ-
ces, and flocci of coagulable lymph, too plainly
indicated the insurmountable mischief which had
already been produced within the cavity of the ab-
domen, and of which she died in the course of
the evening
Bootstagood osoba
a
a

FEMORAL HERNIA. SE
327
a
I opened the body the following day. The
whole of the peritoneum was in a state of inflam-
mation. That portion of it which formed the
mouth of the hernial sac, was much more inflamed
than the rest, and very considerably thickened.
The protruded intestine had given way for nearly
half its circumference, on that side which lay next
the symphysis pubis, and from the aperture thus
formed, the fæces had escaped into the abdomen.
No gangrene, however, had taken place, but the
opening appeared as if the intestine had been cut
to that extent by a pair of blunt scissors.
This case affords a striking proof of the propri-
éty of making the division of the mouth of the
sac towards the symphysis pubis, in the operation
for strangulated femoral hernia; and shews that
less reliance is to be placed for the removal of the
stricture, either in the division of the ligament
described by Mr. Hey, or of Poupart's ligament,
(both of which were completely divided, in the
case I have now related, without producing a suf-
ficient liberation of the incarcerated part) than on
the division of the mouth of the sac. The intes-
tine having given way, also, in this direction with
out gangrene, clearly shews in what part the most
injurious effects of that pressure are likely to take
place, and which, indeed, might be expected to
take place in that situation, from the sharp and
definite edge of the tendinous fibres, which pass
from Poupart's ligament to the pubis, and which
8

328
TWO CASES OF STRANGULATED
form the inner boundary of the foramen, through
which crural hernia descends. In the case I
have described, it is also worthy of remark, that
the peritoneum itself, at the mouth of the sac, was
so much thickened, that I am persuaded the intes-
tine could not have been returned without a very
undue degree of violence, unless the mouth of the
sac had also been laid open. And I have no doubt
that the same obstacle is formed in many cases; as
the pressure at the stricture must necessarily be
reciprocal, between the part confining and the
part confined; and must tend to excite inflamma-
tion and thickening in both, so that hence will
arise one chief cause of insufficiency in any open-
ing for the relief of strangulated hernia, in which a
division of the mouth of the sac is not included.
bosco
CASE II. dio
This was a case of femoral hernia, in which the
sac containing the intestine, was included within
another sac, into which it had descended, so as
completely to fill up the aperture, to which it
firmly adhered. And as the cases of this kind on
record are not numerous, I have thought it might
not be amiss to lay an account of it before the
Society
stala
Mrs. L. had been afflicted for some years with a

FEMORAL HERNIA.
929
femoral hernia, from which, however, she had not
experienced any great inconvenience. It had pro-
bably been in a state of strangulation for two days,
as during that period she had no evacuation by
stool, and had been affected with sickness. She
had not, however, suffered much distress till this
evening, when great pain came on, both in the
part and in the abdomen, and the vomiting be-
came more frequent and severe, on which account
I was desired to see her.
a
I found her with a full and hard pulse, and con-
siderable tenderness over the abdomen, which had
much increased during the last two hours. But I
was fully convinced, from the globularity and in-
compressibility of the tumour, that no effort to re-
duce the protruded parts would be likely to suc-
ceed. It is well known, that some fluid is gene-
rally effused into the hernial sac when strangula-
tion takes place. In favourable cases, the pressure
which is employed to reduce the intestine, will
force this fluid into the abdomen, in consequence
of which the tumour becomes somewhat less, and
rather softer ; but where this does not take place,
and the tumour retains that incompressible rotun-
dity to which I have alluded, it is evident that the
stricture must be exceedingly tight, and the intes-
tine consequently exposed to the most imminent
peril. This symptom alone, therefore, will gene-
rally be a sufficient reason for proceeding to an
immediate, or, at all events, to a speedy operation.

330
TWO CASES OF STRANGULATED
I therefore determined, in this case, to operate
immediately, and release the intestine from its con-
finement, and to bleed the patient * afterwards.
On laying open the hernial sac, about a table-
spoonful of fluid was discharged, and a substance
presented itself unlike intestine, which, on tracing
it upwards, I was soon convinced was another her-
nial sac contained within the former; I opened
* Bleeding is undoubtedly a remedy of great value for the relief
of strangulated hernia; but it has been well observed, that its uti-
lity is chiefly confined to the early state of that occurrence; for,
when the part has been long strangulated, and the strength of the
patient is beginning to fail, from the influence of the disease, the
debility induced by the loss of blood may greatly add to his dan-
ger,
and be itself far more hazardous than the operation. A si-
milar observation will hold good with respect to the warm bath,
and the employment of tobacco clysters; each of which I have
seen, in different cases, decide the patient's adverse fate. The
kind of inflammation also, as well as the degree, demands as
much attention in strangulated hernia as in other injuries. After
compound fractures, when the strength becomes exhausted, the
inflammation often degenerates into an asthenic kind, which de-
mands a directly opposite mode of treatment to that which was
at first required; and in which, therefore, bleeding may be pro-
ductive of incalculable mischief. The same thing may, and I
have no doubt often does, take place in many internal diseases,
and in strangulated hernia : where asthenic inflammation may,
therefore, spread from debility, and destroy the patient, even
though the reduction of the intestine have been accomplished.
Even the fatigue attending the employment of the warm bath,
and other uncertain means, will often occasion more danger to
GO
the patient, on this account, than could result from the operation
itself.
go boce

OFEMORAL HERNIA. ZEST331
this with the greatest care: it contained about the
same quantity of fluid, with some omentum, and a
portion of the ileum. I divided the stricture in
the direction of the symphysis pubis, and returned
the protruded parts without difficulty.
CO
This operation was performed between one and
two o'clock in the morning. The patient was im-
mediately relieved from much of the pain she had
before suffered; and as she was much fatigued, she
was laid in bed, and a solution of sulphate of mag-
nesia was directed to be given every two hours.
At eight o'clock in the morning I found the pulse
still hard and strong ; but the vomiting had ceased,
and one stool had been procured. Twelve ounces
of blood were now taken away, and the sulphate of
magnesia was directed to be continued. Copious
evacuations by stool took place in the course of the
day, and the patient recovered without any unto-
ward occurrence.
a
Some years ago, I saw another case in which one
sac was included in another. This was in a fe-
male patient at St. George's Hospital, on whom the
late Mr. Gunning operated for strangulated hernia.
After opening the sac, something, which at first
was supposed to be a portion of the intestine, was
contained within it; but on attempting to reduce
this, it was found attached to the mouth of the sac,
and to have an unusual appearance. Mr. Hunter,
who came in, perceived by pressing it, that it was

332 TWO CASES OF STRANGULATED FEMORAL HERNIA.
a
sac.
a thin transparent membrane, containing a bloody
fluid; and, on opening it, it proved to be a second
Within this was the strangulated part, which
readily slipped up on gentle pressure. This pa-
tient unfortunately died of peritoneal inflamma-
tion; and it was found, on dissection, that the left
ovarium had been the part strangulated, from
which inflammation had diffused itself generally
over the cavity of the abdomen.
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