On the Treatment of Irreducible Intestine in Herniotomy
Authors: F. A. Southam
Journal: BMJ (1885)

able -eondition, on t4eptein)er 19th chloroforsa was administered; amid, the sac bqing emptied, the following operation was performed, Listerian precautions locing used.Au incisioli was miiadte froimi just above the external ring, on the iiglht side, tlhrougl the whiole length of the serotiun,.utntil it ter- miiiatedl i;miediately below the posterior wall of tlhe sac, that is, the centre of the lower cud ot the testis ; and, in tlhis way, all the struc- tirres down to the sac were severally incised.The apex of the lattcr, which was not openied, was cleared away from the imargins of the external ring andL struictures of tlhe cord b)y means of a Brodie's lirector; tand, beingcr then helLd betweeni the forefinger andl tlhumb, it was pulled down as iiiuclh as safety would permit, so that its Ihigliest poinit couldl be deligated by a chromnicised catgut-ligature.Just below, withai j)air of scissoirs, the sac was cut across, the upper end imilmediately slippling w-itlhin the ring ; andi( the lower portion, except the p-art attaclhedt to time testicle, was removedl by dissection, dullC care lbeincr takeni to avoidl injuring cither the vas tlefereus or the vessels accomnpanying, it.All bleeding p)Oinlts having beeni secured or arrested, the pillars of the external rina were approximatetd Iby four points of interrupted silver -%ire sutuire, and the scrotal wound coa;pted by gut-sutures applied and tiecd at very slhort intervals; at the extreme lower limit, and at the miiost dependenit point, a smiiall aniid short glass dIrainage-tube was iniserted.Thle gauze-dressings hlaving-beei carefully and systematically applied, and due conveiii- ence for micturition also afforded, the little patient was returned to hlis cradle.September 13th.The report stated thlat, iminediately after the operation, anid for many lhours, the cllild was very faint, and at times muelt collapsed.lI'estoratives were freely used, and eventutally rally- ing commenced, and reaction was fully establishe(l.There had been no sickness, neither was there the slightest abdominal tenderness.Thb dressings, being in good position, were undisturbed.Septemberl 14tll.rhe wound was dressed, the drainage-tubc being, l o-ved.c)eptember 16th.The wound was redressed; it had a very healthy ;1:pearance..leptember 19th.Lister's dressiing was discontinuied, as the wound was healing fast.Uminguenitunm boracis was applied; and, in a few ,lays, the healing was comnplete andt sound.Three or four weeks atterwards, the clhiltd commiiiienced. to hiave whooping-cough ; and, in snite of this severe and(1 trying test, the radical cure continiued.No truss hias been worn since the operation.This case causes reflection as regards (1) the age of the patient ; (2) eRIC or two points in connection with the operation.1.The patient was young, andL with truth I thiink it may be added very young-an uinweaned baby carriel in the arms; and probably, unless tlhe spray had1 anything to do witlh it, this circumstance was the cause of the very prolonged slhock which followed( the operation.On several occasions, 1 have noticed the (lepressing effect of surgical operations uipoii youn cluildren.;they bear the operatiolns wvell, but thev bear the shock of theil) badly.2. The points in conlnection witlh the operation are tlhese.a. Tlle sac was ligaturemd before it was opened; and it was detached from above downwards, insteadl of, as some surgCons prefer, from below up- wai ds.b.The pillars of the ring were carefully stitched together, and clused by fourl silver wire sutures, and so there is every reason to be.lieve they still remain an evidence of the a(dvantage, as well as of the neclessity, of using miietallic rather than catgut sutires; for with tlb formier you are enabled permanently to place an effectual barriri against the re-formation of a fresli sac andl hernia.