A CASE IlYDROCEbE OF THE ROUND LIGAMENT MISTAKEN FOR AND OPERATED UPON AS A STRANGU- LATED HERNIA, WITH REMARKS. BY CIIAS. A. HART, M. D., New York, MEMBER OF TIIE AMERICAN MEDICAL ASSOCIATION; OF THE NEW YORK ACADEMY OF MEDICINE : OF THE NEW YORK PATHOLOGICAL SOCIETY. ETC. NEW YORK I). APPLE TON •& COMPANY, 349 & 551 DR0ADWAY. 1872. A I) VERTISEMEXTS. NEW MEDICAL WOJtKS IN PRESS. I. A TREATISE OVARIAN TUMORS, THEIR PATHOLOGY, DIAGNOSIS, AND TREATMENT, WITH REFERENCE ESPECIALLY TO OVARIOTOMY. By E. R. PEASLEE, M. D., LL. D., Professor of Diseases of Women in Dartmouth College; one of the Consulting Surgeons to the N. Y. State Woman's Hospital; formerly Pro- fessor^ of Obstetrics and Diseases of Women in the N. Y. Medical College; Corresponding Mem- ber of the Obstetrical Society of Berlin, etc., etc., etc. II. On Puerperal Diseases. CLINICAL LECTURES DELIVERED AT BELLEVUE HOSPITAL. By Fordyce Barker, M. D., Crfnieal Professor of Midwifery and Disease- of Women, in the Bellevne Hospital Medical College; Obstetric Phvsician to Belle- vue Hospital; Consulting Physician to the New York State Woman's Hospital, and to the New York State Hospital for Diseases of the Nervous System; Hon- orary Member of the Edinburgh Obstetrical Society, etc., etc. III. A Treatise on Diseases of the Bones. By Thomas M. Maukoe, M. D., Professor of Surgery in the College of Physicians and Surgeons, New York, etc., etc. IV. ON THE Treatment of Pulmonary Consumption, BY HYGIENE, CLIMATE, AND MEDICINE. By JAMES HENRY BENNET, M. D. SECOND EDITION, REYISED AND ENLARGED. D. APPLETON & CO., Publishers, 549 & 551 BROADWAY, NEW YORK. A CASE HYDROCELE OF THE ROUND LIGAMENT MISTAKEN FOR AND OPERATED UPON AS A STRANGU- LATED HERNIA, WITH REMARKS. BY CHAS. A. HART, M. D., New York, MEMBER OF THE AMERICAN MEDICAL ASSOCIATION; OP THE NEW YORK ACADEMY OP medicine; OP THE NEW YORK PATHOLOGICAL SOCIETY, ETC. NEW YORK: ^ -- D. APPLETON & COMPANY, 549 & 551 BROADWAY. 1872. A CASE OF HYDROCELE OF THE ROUND LIGAMENT MISTAKEN FOR AND OP- ERATED UPON AS A STRANGULATED HERNIA, WITH REMARKS. Maech 3, 1867.—Mrs. P., aged about forty-five years, was thought by her family attendant, Dr. B., to have a strangulated femoral hernia; he called upon Dr. J. M. C. to operate for him, who, after having visited the patient, called upon Dr. 'R. Nelson to mention the case, and consult with him, giving him the following imperfect history: " She had had more than one child : she thinks that the tumor in her right groin appeared about fifteen years ago, after straining in labor; she had never been able to reduce it, nor had it ever given her pain or inconvenience." What her present illness may be, Dr. C. does not know; he has seen her only once, having been called by her family-doctor to operate for strangulated femoral hernia, which is all he has to do in the case. Dr. C. suspects chronic incarceration, and at present strangulation, because the patient has vomdted once. He has tried taxis ineffectually. He says, " It is surprising how soft the tumor is, and remarkably thin the parietes are.'1 4 CASE OF HYDKOCELE The patient was very much averse to any surgical interference, but, having consented to an operation at the urgent request of her husband and medical attend- ant, at 8 o'clock was brought under the influence of chloroform, while in bed ; and, when fully anaesthetized, carried into the front parlor (where several assistants were waiting), and placed upon a table for operation. The tumor was now exposed, which was found to be larger than a hen's egg, flattened, situated above Pou- partfs ligament, and in the direction of the inguinal canal. Dr. C. made a slight and ineffectual attempt at taxis, which served only to drive the contents of the tumor in a contrary direction, to one or the other side, or up- ward, which, as soon as pressure was discontinued, returned to its former size, site, and appearance. Dr. N. was requested to examine the tumor, and did so, recognizing at once its nature, for he immediately placed his hand above the tumor to exclude lateral light, and requested me to hold a candle close to it, which I did, when the diaphanous character of hydrocele became strikingly apparent. The parietes of the tumor iuere not tense, but soft. There was no opportunity afforded for advice or caution, as Dr. C. immediately commenced his operation by making an incision through the skin transversely across the abdomen, at least an inch and a half above Pouparfs ligament, about four inches long, and another incision bisecting the first vertically, about three inches in length ; the upper line of this cut lay on the abdomen, the lower one across the tumor as far as its lower border, bringing into view a smooth, bluish, and translucent sac. The four corners of the crucial cuts were dissected up, and the whole tumor exposed, which could now no more be reduced than before. A prolonge 1 attempt was now made to OF THE BOUND LIGAMENT. 5 separate an expectant fascia, by repeated scratching and division of thin laminae of cellular tissue, raised by thrusting a director under their leaves, one after another, without meeting any, until tlje parietes of the tumor became so thin that the contained fluid began to ooze out. (The operator, thinking the blue tumor was intes- tine, was surprised that the sac had no fascia.) Dr. N. repeatedly advised, " Cut into it, it is not intestine you have here,''1 when Dr. C. thrust an exploring needle into it, on the withdrawal of which about three ounces of a clear, limpid fluid spurted out, arch-form, resembling hydrocelic fluid; at this stage the supposed hernial tumor quite disappeared. The sac which had con- tained the fluid was now freely laid open in search of intestine, or omentum, but neither was found; but a long, thick, fatty mass lay in the canal of the round lig- ament, free in front, but adherent behind. This was in no way inflamed or discolored / it was said to be incarce- rated omentum, but attempts to either reduce it or pull it down were equally unavailing. After considerable manipulation the lower end became detached from its adhesions to the canal, and by pushing and tearing was separated as far up as the internal inguinal ring, when an ineffectual attempt was again made to return it within the abdomen. This failing, it was decided to cut it off; before this could be carried into execution, Dr. N. managed to press his fingers through the elongated meshes of which it consisted, and in this way severed it into four or five strips, three of which, supposed by the operator to be omentum, were cut off, from the ends of which a few drops of blood oozed, furnished by a couple of arterioles the size of fine hairs: these were ligated. The determination being to make the case one of hernia, the finger was worked in the direc- 6 CASE OF HYDROCELE tion of the canal into the abdomen, and the remaining mass thrust in, and the wound closed by wire sutures, compresses, etc. The little blood that .oozed came from a fleshy fibre of the hypertrophied fibres of an analogous cremaster muscle. The fatty structure had not the slightest re- semblance to omentum, but resembled in some degree a spermatic cord, and was composed of granular fat. The after-history of the case (except that recovery had taken place), I remained in ignorance of until October 26, 1870, when, having an opportunity of seeing the patient, she furnished me as clearly as she could remember the history of her complaint from the time of discovery, about eighteen years ago, when she first noticed the tumor while bathing, about two or three months after a not severe confinement. The tumor was then hardly the size of a filbert, and unattended with pain ; she made repeated efforts to reduce it, sup- posing it to be a hernia, but never succeeded, nor has it ever disappeared during the recumbent posture. The tumor, without causing either pain or inconven- ience, steadily but slowly increased until it attained the size it was at the time of operation in 1867; fol- lowing Avhich she kept her bed for six weeks, though the wound was closed at the end of three. A short time after, being about again, she noticed a commencing return of the tumor, which at the present time has attained about the same size as the original one, and, like it, of gradual growth and free from pain. Her former experi- ence not being of a pleasing kind, she has adopted the precaution of wearing a truss (being still under the im- pression that th^ tumor is hernial), but with the effect of merely flattening the tumor, as it has never been re- duced. OF THE ROUND LIGAMENT. 7 I regret exceedingly that the lady's extreme repug- nance to an examination could not be overcome, as more information might have been gained. The pathological conditions found in this case can,I presume,be considered as typical of this extremely rare form of disease; of which I know of but two other instances which came under the observation of Dr. R. Nelson, both of which possessed the same physical characteristics oitranslucency, slow growth, non-reducible, and free from pain: no operation was performed in either case. The literature upon this form of disease is extremely scanty, it being mentioned, as far as I am aware, only in the older editions of JEtius, Pare, Scarpa, Meckel, and Poland. That the disease occurs more frequently than is generally supposed there can be but little doubt; but, not being mentioned or classified in the modern medical works, it is confounded with other diseases, and not recognized in its true nature. Medical Works pblisM iij D. 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