694 THE BRITISH JOURNAL OF SURGERY

SHORT NOTES OF RARE OR OBSCURE CASES.

TWO CASES OF STRANGULATED RETROPERITONEAL HERNIA INTO POUCHES IN THE BROAD LIGAMENT. BY C. H. FAGGE, LONDON.

I HAVE failed to find other examples of this lesion, either from a.search of available literature or from the experience of fnends, though it is not to be expected that similar cases have not been observed. In both instances I was able to convince myself that the bowel was contained in a peritoneal fossa, and had not been forced into connective tissues through a rent ~1 the posterior peritoneal surface of the broad ligament. In the first case the pouch was below the ovarian ligament, and I cannot find any descnption of any pouch in this position, in the second the pouch was above the ovary and below the tube. where, I gather, a definite fossa is recognized by gynaecologists, though not, as far as I know, described by anatomists.

Case 1.-Mrs. Y., age 61, the mother of five children, was seized with sudden abdominal pain on Dec. 9, 1916, while straining at stool immediately after breakfast. The only history of any accident was a fall downstairs in 1902. Beyond haematemesis in 1905, there was no history of any abdominal trouble. The pain was referred to the left iliac region, and she vomited several times, during the day she passed two normal motions. On a second visit, about 4.0 p.m., as pain continued to be acute, Dr. Stilwell d'ecided that it was an abdominal emergency, and admitted her to the Beckenham Cottage Hospital after injecting a quarter of a grain of morphia. I saw her at 7.0 p.m., when the pain, which had been relieved by the morphia, was beginning to return , her pulse was 108. nothing was to be made out on abdominal examination, except marked tenderness low down iri the left iliac region, the tongue was clean, but her aspect was anxious, and in view of the history of agonizing pain, immediate operation was decided upon. No exact diagnosis was attempted before operation ; the conditions which wcre considered as most likely were torsion of an ovarian cyst, strangu- lated obturator hernia, or mesenteric thrombosis. When under the anaesthetic, vaginal examination detected a fullness of the left posterior fornix, and rectal examination confirmed the presence of a mass in Douglas's pouch. A left paramedian sub-umbilical incision exposed collapsed small Intestine, and lower down and to the right was a coil of ileum which was distended and purple, it could not be drawn out, RARE OR OBSCURE CASES 695 and was evidently held down in the pelvis. This and aiiother’collapsed coil were traced down to the left side of the pelvis, where they were caught and Iic d tensely as they passed through a small hole in the peritoiieum , they were obviously the afferent and eflerent coils of the strangulated loop, which could be seen and felt under a layer of peritoneum, filling np the left half of the pelvis. It was at first thought that this orifice was the entrance to the inter-sigmoid fossa, but to the left the peritoneum passed over the pelvic brim, and below its margin was continuous with a tense layer of peritoneum passing on to the sidc of the nterus. The margin of this opening was now divided with scissors, allowing the distended purple loop of ileum to be with- drawn, when it was found that this loop had passed from behind forwards into the broad ligament, and, filling up Douglas’s pmch, had formcd the mass which was palpablc through the rectum and vagina. The strangulated coil was covered with hot cloths while the opening in the broad ligament-just below and median to the ovarian ligament-was closed with a continuous catgut suture. The loop actually strangulated was about ten inches long, and above this about two feet or more of ileum were distended and injected. The whole was of good tone and had a shiny perito- ncal surface. therefore, as it had only becn strangulated some clevcn hours, it was pdgcd to be viable and returncd to the abdomen, which was closed, with a large rubber drain passed down into Douglas’s poiich. Subcutaneous saliiic had been given throughout the operation, and rectal saline was given during the following night. The next morning there was considerable abdominal pain, with disten- tion of the lower abdomen, there was no sickness, but mnch offensive gas was eructated. Water by the mouth and pituitrin were given, shc had some sleep after a morphia injection, saline was given per rectum, and on Dee. 11 she had & gr. of eseriiie, after which a good deal of fliud deeply colourcd with blood was passed per rectum. Eructation now ceased, and several loose motions were passed during the ncxt two days. Recovery was only prejudiced by a mild bronchopneumonia on the sixth day In February, 1917, she had another attack of severe left-sided abdominal pain, and this reciirrcd in March, she was admitted to Guy’s Hospital, whcrc an a-ray examination after a bismuth meal gave no definite evidence. On March 12 the abdomen was again opened, and extensive adhesions between the sear and the lower ileum were freed, the hole in the left broad ligamcnt was still closed. In January, 1918, Dr. Stilwell reported that the patient rcmaiiied well.

Case 2.-Miss P., age 49, was seized with abdominal pain at 2.0 a.m. on Nov 30, 1917, she vomited at intervals, and her bowels acted twice. Dr. Mow11 saw her on the morning OP Dec. 1, when she did not appcar acntcly ill, her pulse-rate and temperature were normal, she continued to vomit occasionally, and the pain was not severe. On the next day she was not so .ivcll, and fainted. On Dee. 3 she still vomited occasionally, and the pain, located to the middle of the abdomen, was severe, there was now slight rigidity and tenderness over the right rectus slightly internal to McBiiriiey’s po111t. Dr. Mow11 diagnosed appendicitis, and admitted her to Sinbiton VOL. V -NO. 20. 49 696 THE BRITISH JOURNAL OF SURGERY

Cottage Hospital, where an enema was given with no result; her pulse was then 86, and her temperature slightly raised. When I saw her, at 7.0 p.m. on Dec. 3, her pulse-rate had risen to 100, the physical signs were unaltered since the morning, and did not suggest a grave abdominal condition. The history of the attack and the location of the pain to the right iliac fossa naturally led Dr. Mow11 to the diagnosis of acute appendicitis, with which I candidly agreed, the point of chef tenderness was perhaps more than usually median, but this might have been occasioned by an inflamed appendix hanging over the pelvic brim. A free right paramedian incision exposed a healthy appendix, the small intestine was slightly distended, and there was an abnormal amount of clear fluid in the peritoneal cavity, on passing the hand into the right side of the pelvis, a coil of the lower ileum was found to be fixed to the back of the right broad ligament. Further exposure, with traction, showed a blue cystdike body in the substance of the ligament to the back of which the loop of ileum led. After the experience of the first case, I recognized the condition present, and, defining the upper crescentic margin of the orifice, I cut it with scissors, releasing about two inches of ileum, congested but shiny, and with anrcmic rings at the two ends where constriction had been caused by the margin of the ring; it had just the usual appearance of a similar coil released from a strangulated femoral hernia. I could now demonstrate that the pouch into which it had passed was above the ovary and its ligament; and, as by the division of its neck it had been converted from a saccular pouch into a shallow fossa incapable of encouragmg a similar retroperitoneal hernia, I did not thmk its obliteration by suture necessary. The abdomen was closed without drainage. The patient made an uninterrupted recovery, and left the hospital on the sixteenth day. She has remained well since.