APPENDIX" IN RELATION TO INGUI- NAL HERNIA AND A NOTE ON LOCAL ANAESTHESIA.

By T. S. SHASTKY, MAJOR, I.M.S.

(District Medical Officcr, North Arcot, Vellore.) f]1prp |lftVp During the last fifteen months, mere nave

been 52 cases of inguinal hernia operated on in the Government PentlancI Hospital, Vellore in which the appendix was seen in the contents ?f the sac in 6 cases.

Case 1.?A male, aped 49 years, operated on 22nd February, 1929, for inguinal hernia of right side.

Appendix found adherent to the posterior wall of the

sac for about 2 inches. The gut could not be delivered, so the sac was tied and pushed in without appendicec- tomy?modified Bassini's operation under general

anaesthesia (chloroform); discharged on 12th March

1929.

Case 2?A male, aged 45 years, operated on 23rd

July, 1929 under chloroform for right inguinal hernia This proved to be a case

of "sliding" hernia. The gut was adherent to the posterior and lower part of the

sac. The posterior wall of the sac was composed of

394 THE INDIAN MEDICAL GAZETTE. [Jui,y, 1930.

the caecum and appendix. Appendix was not removed. Modified Bassini's operation was done. Discharged on 7th August, 1929. Case 3.?A male, aged 40 years, operated on 30th

September, 1929, under chloroform, for strangulated inguinal hernia of right side. On opening the sac, about 6 ozs. of clear yellow fluid escaped; the caecum and appendix were in the sac. The caecum was

congested. Constriction was at the neck of the sac.

Appendix was removed and contents reduced. The patient was discharged on 14th October, 1929.

These three cases were operated by my predecessor Dr. V. P. Kamath.

Case 4.?A male, aged 50 years, admitted on 7th February, 1930, for recurrent obstructed hernia of right side. History of having been operated upon for strangulated inguinal hernia eight years ago in this hospital and of its having recurred two years after the operation. This time the hernia is of 6 years' duration and the obstruction is of 3 days' duration. He sought admission for severe pain in the scrotum and lower abdomen, constipation and vomiting. He had hiccough, and the hernia was irreducible. The tongue was dry. He looked rather emaciated and worn out. Turpentine enemas were given, with no result. The stomach was washed out. Washing showed nothing particular. The hernia was a huge one, the size of a big coconut. He was given a preliminary injection of morphine and atropine subcutaneously, and the operation was done under local infiltration anaesthesia Q per cent. Novo- caine solution with 5 minims of liquor adrenaline hydro- chloride to an ounce). The scrotum was about 12 X 10 X 6 inches. The ring of the neck admitted four fingers; the sac was about 9 inches long, fully adherent to inside the scrotum, testes, cord, and the bowels.

Contents of the hernia were: (a) the appendix and caecum, intimately adherent to the sac; the appendix was 5 inches long and 1 inch in diameter?constricted near the caecal end, the proximal 2 inches was distended with pus; distally it was normal; (b) the ileum which showed congestion and one patch of excoriation, the muscle was exposed and had some adhesions'. There was no perforation. About three feet of ileum were lying free in the sac. The contents could not be fully dissected out of the sac. The ileum was pushed in, and the appendix was excised. The sac round the caecum was purse stringed, so as to cover the caecum fully, and the whole pushed in and transfixed to the internal oblique muscle. The canal was closed in the usual way. A lof of blood-stained fluid was found in the sac, the cord was cut and the right testis was excised as the cord was very long and adherent. A counter opening was made in the scrotum and a drainage tube left in. He was discharged cured on 9th March, 1930.

Case 5.?A male, aged 38 years, operated on for left strangulated inguinal hernia on 14th March, 1930. He was operated on for right-sided hernia ten years ago in this hospital. Turpentine enemas had no effect. The stomach was washed out?nothing abnormal. He was given a preliminary injection of morphine and atropine subcutaneously. Local infiltration amesthesia was performed. In the sac were found a large amount of mesentery with dark blood extravasation and very congested ileum about 3 feet long. The caecum and appendix (left-sided hernia) were just above the ring in the abdominal cavity, but came out into the npek of the hernia when he strained. The appendix was very hard and thick and intimately adherent to the caecum, it was covered by fascia-like membrane, so as to look as if it was incorporated with the caecum, only the distal \ inch was lying somewhat free. The appendix was released and excised, it was four inches in length; and the hernia was reduced. The coils of ileum were contracted to the thickness of the thumb. The opera- tion was completed after Bassini's method. He was discharged cured on 21st April, 1930. The appendix snowed chronic inflammation on section.

Case 6.?A male, aged 55 years, admitted on 12th

March, 1930, was operated on for bubonocele of the

right side on 25th March, 1930, under local infiltration anaesthesia with preliminary morphine and atropine injection. There was no sac at all. The caecum and appendix were discovered in a meso-caecum and meso- appendix. The appendix was coiled into 2/3 of a

circle, a scar was found on the meso-appendix. The

appendix was removed. It was normal on section,

except for many threadworms. The meso-caecum was closed round the caecum. The whole was pushed in, and the external ring closed.

Since January this year, twelve cases of hernia were operated on nnder local anesthesia. The procedure was as follows:?Ordinary cases were given castor oil the previous forenoon, and an enema was given 'the same evening- One hour before operation, a preliminary sub- cutaneous injection of morphine \ gr. and atropine 1/150 gr. was given. A solution of Novocaine ^ per cent, is freshly prepared and sterilized and to it 4 or 5 drops of liquor adre- nalin hydrochloride are added, per ounce of the solution, before infiltration. In the line of incision the skin and subcutaneous tissues are infiltrated with the solution, and the operation is commenced 5 to 10 minutes after. The muscular layer is then infiltrated and then the

sac. The operation is well borne by almost all patients. Thirty to forty c.cm. of solution were used for each case. The advantages are very many, when compared to general anaes- thesia under chloroform.

First, the shock is practically nil. Secondly* there is no post-anaesthetic vomiting or delay- ed chloroform poisoning. The patient can take nourishment soon after. Usually, we give him some milk and water after operation.

Thirdly, it is specially indicated in diabetic and consumptive subjects.

Fourthly, it is very useful in otherwise diseased and debilitated subjects, who obvious- ly cannot stand chloroform.

Fifthly, you dispense with the necessity ?*

the services of a skilled anaesthetist.

The one point I should stress is that thc

solution prepared should be absolutely frcS! and sterile. I have also done a few of ^ cases under spinal anaesthesia, which also ha

given very satisfactory results. The theory that the patients' shoulders or heads ought be propped up higher than the abdomen for iea, of the solution going, up the cervical cord aI1, stopping respiration can certainly be ignore

?

The patients after injection of spinal anaostne^ tic (either Novocaine or Stovaine) were #?Perav ted upon in Trcndelenberg's position ifl ^ work in this hospital, without the least dange

*

? -fllC I have great pleasure in acknowledging

part of my Assistant Superintendent, Dr. A- '

Verghese, l.m.s., and my Sub-Assistant Surge '

Dr. P. Srinivasan, l.m.p., in preparing notes.