Strangulation of a Hernia Sac

American Journal of Surgery

OCTOI~iP2R,1926

C O M M E N T A N D CORRESPONDENCE mined to our own satisfaction t h a t with a standardized technique, the level reached by Editor, AMERICAN JOURNAL OF SURGERY~ the anesthetic varied in different individuaIs. In your issue of June, I926 appears an article This is probabIy due to the fact t h a t the epib y David C. EIiiott, .M.D., entitIed " X - R a y duraI space varies somewhat in size in different Studies on Caudal Anesthesia and the Intra- individuaIs and t h a t the anesthetic effect may venous Absorption of Substances Injected into differ to some extent in one person as compared the Sacral Canal." with another. As I carried out a somewhat similar series of The point made by Dr. EIIiott in confirming experiments in I924 and published m y resuIts the observation of Thompson that there is in Archives oJ Surgery, March, I926, and as danger of injecting the solution into the venous these experiments are to some extent corro- system is an extremely important one. It is borated by the findings of Dr. EIIiott, I crave probably true t h a t this accident m a y foIIow your induIgence whiIe making the foIIowing the rupture of a vessei wail. T h e only safe comments. procedure is to aspirate frequentIy whiIe the While it is probably true that in the unem- injection is being made, and to desist at once balmed cadaver definite amounts of fluid provided blood-stained fluid is withdrawn. injected into the epiduraI space through the Since our experiments were made in I924, sacraI canaI wiII reach approximately simiIar it has been our practice to use smaIIer amounts levels in individuals of the same size, we must of the more concentrated solution (novocain, bear in mind t h a t in the practical use of sacraI 3 ° to 6o c.c. of I per cent to z per cent soIution) anesthesia other factors must be taken into where the anesthetization of the saeraI nerves account. It is patent t h a t in the cadaver, onIy was the main objective. especially after rigor mortis has become estabT h e injection of tetro-iodo-phenoIphthaIein lished, the dissemination of liquids wilI differ empIoyed by Dr. EIIiott in the living subject is to some extent from the phenomena which extremeIy ingenious and the results obtained take place when simiIar fluids are injected in are most interesting. the Iiving subject. Furthermore, it is obvious ROBERT EMMETT FARR, M.D. t h a t isotonic soIutlons wiII be absorbed more MINNEAPOLIS, • rapidIy into the tissues of the Iiving subject July, 12, I926 than will solutions that are not isotonic. From the practieaI standpoint clinical experi- STRANGULATION OF A HERNIA ence shows that the height reached b y anestheSAC tic solutions injected into the sacral canaI depends upon a number of factors and cannot Editor, THE AMERICAN JOURNAL OF SURGERY, In your comment on my article on Gangrene be definitely estimated b y the amount injected. The force of gravity and the rapidity with of a Hernial Sac, both of which were published which the fluid is injected wiII both influence in the August issue of the JOURNAL (p. IO3, - make no mention of fluid the resuIt. With the patient in the TrendeIen- p. 108) yOU " burg position an isotonic solution wiII be found within the mass; observation of analogous to reach a higher IeveI than when ttle prone conditions would Iead us to expect t h a t if or reverse Trendelenburg position is a s s u m e d gangrene of the sac were caused by strangulawhile the injection is being made. It wiII be "' ti~)n (which, however, Miller does not assert) found, also, t h a t anesthesia m a y be noted at a i t would contain serous or sero-sanguinous higher leveI when the injection is made in, fluid." This is quite true where the gangrenous say five minutes, than when twenty minutes sac contains a strangulated intestine or omenare aIIowed to dapse during the introduction tum. However, in the fourth paragraph of my of a given amount. T h e reason for this is articIe I stated explicitIy " t h e r e was no disobvious. T h e sIow injection permits the charge of any kind from this incision . . . " dissemination of the soIution upward along the Of course not, for the opening at the neck of epiduraI space where the resistance is compara~ the sac leading into the abdominal cavity was tiveIy slight. Between I916 and 1918 we deter- about the size of a silver quarter; and further226

CAUDAL ANESTHESIA

N e w Series, VOL. l, No. 4

Comment and Correspondence

more, the sac did not contain anything Iike intestine or omentum that would have caused an exudation of fluid. In alI m y previous operations, where I had encountered a stranguiated intestinal or omentaI hernia, there was always fluid present upon opening the sac. The only explanation of gangrene of the sac in the case I reported that I can venture is t h a t an intestinal hernia did occupy the sac, and being more viable than the sac, did not become gangrenous, but by pressure against the neck of the sac around the ring caused the rapid change in the sac which I encountered; and when the intestinal hernia sIipped b a c k - as I assumed in my articIe--it aIIowed the fluid to gravitate back in the abdominal cavity. In Dr. Coley's comment t h a t " i t is still more improbable that a portion of strangulated boweI could have produced gangrene of the sac without first having become gangrenous itself; and if such portion of the intestine had been reduced, it eertainIy would have produced a peritonitis," aII experiences so far wouId warrant this conclusion. However, the proof t h a t there was not gangrene of the

A m e r i c a n J o u r n a l of S u r g e r y

227

intestine is t h a t the subject did not develop a peritonitis and is alive today. I cannot agree with Dr. Coley that I might have had a "gangrenous appendix glued to the sac." In the first pIace, as I before stated, the neck of the sac at the ring had an opening about the size of a silver quarter, and careful examination did not Iead me to the cecum. Of course, " i t is very difficult to give a rational expIanation of the case" any more than my personal deduction t h a t a gangrenous mass existed, that it was an empty sac, was removed and no fatality resulted, i t is this very condition that makes the case unusual. The mass, in order to become gangrenous must have had a blood suppIy. M y hypothesis is t h a t this blood supply was furnished b y the omentum becoming agglutinated to the sac. Assuming, then, that this was the case, the viability of the sac being much Iower than t h a t of the incarcerated intestine it caused the rapid change in the sac before the bowel siipped back into the abdominal cavity. H. T. MILLER. Springfield, O. September 26, i926.