A Case of Strangulated Hernia

Mn. H. K., aged 30 years, well built, an athlete, was admitted into the hospital for vomiting and unbearable pain in the right pubic and scrotal regions which began at 3 a.m. the same morning. On admission the pulse was 86 per minute, temperature 98?F., respiration?21 per minute, tongue?dry and thickly coated. The complaint about a swelling appearing and disappearing in the right pubo-inguinal and scrotal area had been of twelve years' duration. The swelling, which used to descend into the scrotum from the abdomen, appeared almost invariably after exertion in the gymnasium and occasionally used to be painful, but after rest the pain and swelling used to subside completely. At about 2-45 a.m. on the day of his'admission to hospital he had a severe fit of coughing, which brought on the swelling in the scrotum and along with it pain which gradually increased and became intense. I examined him carefully and found the hernia to be of a direct type and irreducible and the man was in agony. The hernial swelling was of the size of a big coconut, resonant, but without a gurgle; in fact with all the signs and symptoms of a strangulation. At 1 p.m. the same day after an injection of stovaine into the spinal theca and a subcutaneous injection of 1 c.cm. adrenalin, a three-inch incision immediately above the base of Hesselbach's triangle was made and the hernial sac, which looked blackish, identified. On opening the sac a purplish black fluid welled out and a fifteen-inchlong loop of gut near the ileo-csecal valve was found to be almost gangrenous. It was rigid, purplish black, along with its mesentery which looked and felt the same. There was no visible or palpable sign of pulsation in the arteries. An enterectomy looked obvious but I tried and succeeded in resuscitating the gut, after removing the constriction, with very hot saline for fully eighty minutes. To my surprise and also that of my assistants the gut began very gradually to revive until the whole coil of intestine with its mesentery became active, excepting a patch one and a quarter inches long and three-quarter inch wide on the side of the gut and a triangular patch of mesentery about one and a halt inches long and an inch and a quarter wide at its base which remained purple and hard. Further efforts to revive these patches failed, so I decided to return the coil to the abdomen with the big gangrenous patch