_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.