CASES OF HERNIA OF THE BLADDER MET WITH DURING OPERATIONS FOR INGUINAL AND FEMORAL HERNIA. BY CHRISTIAN FENCER, M.D., CHICAGO. Reprinted from the Transactions of the American Surgical Association, iBgs. CASES OF HERNIA OF THE BLADDER MET WITH DURING OPERATIONS FOR INGUINAL AND FEMORAL HERNIA. CHRISTIAN FENCER, M.D., CHICAGO. Until the last decade, hernias of the bladder were considered as of comparatively rare occurrence; but since the radical opera- tion for hernia has been revived, and has become so common as to be almost an everyday operation, the bladder has been met with quite frequently in the course of these operations. Although the bladder has been encountered in almost all forms of hernia, it is practically only the femoral and inguinal hernias that we have to deal with in this regard. In 1891 Siegel21 collected 73 cases of hernia of the bladder, 48 of which were inguinal; since that time 13 more cases have been reported— .by Roth,19 2by Walther23 (published by Bour- bon),2 and 1 each by Postempski,17 Leszinsky,10 Guelliott,5 Israel10 (published by Feilchenfeldt), Thiriar,22 Reverdin,18 Kummer,12 and Polaillon, to which I add my case. This makes in all 62 cases of inguinal hernia of the bladder. In 1893 Guepin6 col- lected 8 cases of femoral hernia of the bladder, 1 case being reported by each of the following operators ; Levret, Habs,9 Giiterbock,7 Cooper, Aue,1 Schoonen,20 and 2by Lang.13 To these I add my 2 cases, making in all IO femoral hernias of the bladder. In the great majority of these cases the hernia was not sus- pected before operation. There has been so much difficulty in recognizing the bladder even during operation, that in most of the cases the bladder was wounded before being discovered ; on 2 FENGER, this account many of the writers on this subject during the last five or six years have paid especial attention to and have de- scribed very carefully all the essential characteristics of hernia of the bladder. One of the chief points in vesical hernias is the relation of the hernial sac to the bladder, which again is identical with the relation of the peritoneum to the protruding part of the organ. This has been clearly yet briefly described by Dieffen- bach in 1848, as follows ; “ Hernias of the bladder have some- times a hernial sac, at other times none. If that part of the bladder which has a peritoneal covering prolapses, there is a hernial sac. If a part of the bladder uncovered by peritoneum protrudes, the sac is wanting. If a portion of the bladder on the border line between the intra- and extra-peritoneal surface comes out, then there is half a hernial sac.” (That is, a hernial sac is present on half the prolapsed surface of the bladder, and on the other half the sac is absent.) The location of the hernia is invariably in the medial and lower part of the respective rings, inguinal as well as femoral; if an intestinal hernia is also present its contents are situated above and to the external side of the vesical hernia. I. We most frequently find the peritoneum of the sac cover- ing only a portion of the prolapsed bladder, its upper anterior surface is clad with peritoneum, but the inferior medial portion is not. The sac, whether empty or filled, is ordinarily larger than the prolapsed portion of the bladder; it extends further out or lower down, so that the bladder is found as a small mass at the neck of the sac only, on its inferior medial aspect. 11. Less frequently a complete sac is found; that is, the pro- truding bladder is entirely covered by peritoneum, as in my case of inguinal hernia. Case I. Synopsis. Left femoral hernia ; no distinct symptoms of hernia of the bladder; radical operation ; bladder not recog- nized and opened; bladder wound sutured and anchored to deep portion of wound ; recovery without leakage.—Miss L. S., school- teacher, aged twenty-three years, was admitted to the German HERNIA OF THE BLADDER. 3 Hospital, February 3, 1894. Family history negative. Aside from the ordinary diseases of childhood she was healthy. At the age of fifteen she suffered from chlorosis, which persisted for four years. A year later she had uterine inflammation, and in August, 1893, a mild attack of scarlatina. Following this she had hysterical attacks, during which she cried and sobbed so much that she thought it might be the cause of the present disease. In October, 1893, she noticed a soft tumor in the left femoral region, which was somewhat tender and could not be reduced by presure. A few weeks later she began to have pain in the tumor, which increased until it became almost intolerable. Patient says that even when a child she would have to be awak- ened during the night to pass water. As she grew older she was obliged to get up once or twice in the night. When she was excited she would have to urinate more frequently. She never had any pain before, during or after urination. Upon examination I found an irreducible left femoral hernia the size of a walnut. Operation, February 5, 1894. The A. C. E. mixture was em- ployed as an anaesthetic on account of albuminuria. An incision three inches in length was made below and parallel to Poupart’s ligament, across the crural opening. Blunt dissection was then made down to the empty sac, which was doubly ligated and the end cut off. Reduction of the stump was impossible. A diffuse lipoma, or rather a conglomeration of adipose tissue, was found on the internal surface and dissected off. When this was cutoff another sac-like cavity was opened, through which a probe passed into the abdominal cavity. I believed this to be the sac of a properitoneal hernia, but as I found, after dissecting off more adipose tissue, another sac, I searched for the relation between them, and found that they all communicated and were folds of the abdominal parietal peritoneum, which was so loosely attached to the surrounding peritoneum that it simulated an independent hernial sac or diverticulum, but was in reality a portion of the first cavity, which was curiously folded upon itself. Upon the dissection of more adipose tissue a third peritoneal 4 FENCER, sac was opened. Still deeper, on the internal surface in the medial portion of the ring was an ovoid body, whitish, elastic, the size of an almond. Upon traction this could be pulled out an inch or more, but no neck could be seen, as the mass filled the entire ring. It looked like an ovary or the anterior surface of a small testicle, but manipulation with the fingers proved that it was a thin-walled empty sac whose walls moved against each other. As I supposed this to be a fourth fold, I cut it open for about two inches. As its surface, although whitish and smooth, pre- sented a slightly different appearance from the peritoneal surface of an ordinary hernial sac, I suspected that it might be the bladder, and my suspicion proved correct, as a sound in the bladder met the finger tip introduced through the opening in the supposed sac. No urine escaped, as the bladder had been emptied by catheter. The bladder wound was immediately united by a row of Lembert sutures of catgut, reinforced by another row. In the centre a heavy silk suture was inserted, with the ends left long to anchor the bladder in the wound, and thereby render the abdomen safe against urinary infiltration. The opening into the peritoneal cavity was then united, the wound packed with iodoform gauze, a permanent soft catheter inserted in the bladder, and the usual dressings applied. A week later the anchor suture was removed. The peritoneal wound was healed. Two weeks after the operation the perma- nent catheter was removed and the patient catheterized every three hours. There was at no time any leakage of urine through the wound, and the patient made a good recovery. She left the hospital after seven and a half weeks. In April, 1895, the urinary trouble was the same as before, but the pain in the region of the hernia had disappeared. She now wears an elastic pad. Remarks.—Opening into the bladder may be avoided: (a) When the hernial sac, after its neck has been loosened, isolated, and ligated, does not pass up readily through the in- ternal ring, but stops in the canal. 1. By constantly keeping the bladder in mind. HERNIA OF THE BLADDER. 5 (