Hernia
Geoghegan
(7826


FARTHER REMARKS
ON
# El
un HERNIA,
IN EXPLANATION OF THE NATURE OF
STRANGULATION,
AND OF
OBLITERATED INTESTINE,
AND IN DEFENCE OF VIEWS AND SUGGESTIONS
TOWARDS IMPROVEMENT IN THE TREATMENT.
BY E, GEOGHEGAN, M. R. C. S.
Honorary Member of the Royal Medical Society, Edinburgh; and
Şurgeon to the Dublin General Dispensary.
IN A LETTER TO
JOHN ABERNETHY, ESQ.
DUBLIN:
SOLD BY CALLOW AND WILSON, PRINCES' STREET, SOHO,
LONDON.----HODGES AND M ARTHUR, DUBLIN.
(1826


HAVING read an interesting communication in the
London Medical Repository of November last, from Dr.
Bishop, of Thornby, in Northamptonshire; headed “ On
the extraordinary Obliteration of the Canal of the Stran-
gulated portion of Intestine, which has occasionally
been produced by adhesive inflammation of its mucous
membrane, in Inguinal Hernia ;” and the author having
noticed my anticipation of such an affection, in publica-
tions on Hernia, and requested farther observations of
mine in illustration of this hitherto unobserved morbid
condition, I attempt the explanation desired, in the
following pages, which I sent to the publishers of the
Repository early in February, considering it an eligible
and indeed the proper channel of communication, under
the circumstances; I am disappointed at the article being
unnoticed and unpublished; however the present copy
is more perfect, and I trust will satisfy Dr. Bishop, and
those of kindred zeal.


ON STRANGULATED HERNIA,
AND
OBLITERATED INTESTINE.
To John Abernethy, Esq.
DEAR SIR,
I take the liberty of again requesting your attention to
the subject I submitted to you in the Edinburgh Medical
Journal some time back; the intricacies in which it seems
involved, invite the inquiries of a master of his art. I
consider strangulation to consist in an impervious gut,
pro tempore, caused by inflammation, confining the con-
tents, which being highly pungent and stagnant, greatly
aggravate the symptoms. The usual treatment of pres-
sing the tumour so inflamed against stiff tendinous bor-

6
ders, to force it through their too narrow aperture, irri-
as
tates the gut so to favour derangement of structure, pro-
ducing the adhesive processby coagulable lymph or ulcera-
tion, thus effecting permanent obliteration of the tube,
when this state has contined long. Dr. Bishop treated a
strangulated hernia three days; on the fourth he operated
so as perfectly to fulfill the curative intention, after
twenty hours violent pain, the termination was fatal ; ex-
amination post mortem discovered the returned hernia
impervious one inch and half in length, the portion which
had been within the aperture pending the strangulation.
Surprised at this, as was Dr. Arnauld who assisted him,
be related the case to Sir A. Cooper, to whom it was
eqnally novel, strong evidence of its being nnknown
to Surgery, and ample excuse for me, were I to grant
that I required any for not having adduced post mortem
facts to confirm my statements, as remarked by Dr.
Bishop and by the able Editor of the Medico Chirur-
gical Review; but as I never pursue the usual treatment,
such an instance could not have occurred to me, my prac-
tice is designed to ascertain and to prevent the imper-
vious state, aware that replacement of the gut so closed
up must prove fatal; my statements often made to this
effect were inductions from facts and from the pheno-
mena of the disease, as I had observed them, and the re-
cords of practice exhibited them. Dr. Heberden in his
Commentaries, mentions the gut perfectly obliterated in
cases of Ileus-the Edinburgh Medical Essays has one of
a man 70 years old, who had an hernia, was seized by
vomiting, fetid excrements, no stools for many days, the
hernia not then outside-on examination post mortem,
the passage at the valve of the colon was shut up, and
two inches breadth of the gut degenerated into an hard
solid substance. The same work has a case in which the

7
sides of the os uteri were grown together firmly, discovered
whilst the woman was in labour of her second child.
The Transactions for Medical and Surgical Knowledge,
has a case from Sir Edward Home, in which two inches
ka
half of strangulated portion of lleum had an in-
flammatory exudation of coagulable lymph, adhering to
different parts of its internal surface, which was ex-
tremely vascular.
a
We know that a tendency to adhesion of mucous sur-
faces is observed in the nose, mouth, cisophagus, thora-
cic viscera, intestines, and urethra of some; in those there
is no irritation from rigid sharp tendens; is it not reasona-
ble then to expect in cases of local inflammation and also
irritation by a Surgeon exerting force against an inflamed
and inflated portion of intestine, in immediate contact
with a tendinous border, nay in femoral hernia with bone
too, that the adhesive process would take place some-
times, and certainly in an individual præ-disposed to it.
One would think that the experiments and observations
of John Hunter, together with the facts recited, were
conclusive on this point, and warranted my anticipation
of such a result as Dr. Bishop discovered, although I
had not, as I could not adduce, post mortem facts of my
own, as evidence of it; the fact of obliteration of the
calibre within the tendinous aperture, and its novelty to
Sir A. Cooper himself, who has been so elaborate on the
subject, indisputably demonstrate the justness of my
,
doctrine, and the error of those who impugn it. Here I
take leave to examine a passage in Sir Astley’s Lecture
on Hernia, as reported correctly, I am satisfied, in the
Lancet, February, 1824, he says
" that cold applications
are useful in removing strangulation, and gives instances

of their success, but that it is an absurdity to attribute
this to diminishing the volume of air, and that if cold
had such a power, it would do no good, nothing could
be gained by it, that the principle is erroneous, diminish-
ing can do no good, whilst pressure is the same, it is of
no use to empty the gut of its contents, &c. &c.” To these
remarks I oppose the following:-The late Mr. Alex.
Munro, in the Edinburgh Medical Essays, contends that
the volume of air is the chief impediment to removing
strangulation, and forbade warmth as calculated to en-
crease it; he quotes Dr. Huxham, who saw an enormous
encrease of distension, owing to warm applications. Am
I to insist in opposition to Sir A. Cooper, that cold has
the power of diminishing a volume of warm air, and that
diminishing whatever is morbidly enlarged can do good,
and is the sine qua non in hernia, and that the pressure
he mentions arises, from a recent tumefaction pressing,
because enlarged against the edges of an unyielding ring,
which is too small to contain it, and which part lay at ease
within it, until the tumefaction occurred by the distension
of air, can we lessen the pressure here, but by diminish-
ing; on what ground can it be said that the principle is er-
roneous, absurd, &c.? The luminous John Bell arranged
as parallel cases, laborious child-birth, distended urinary
bladder, and strangulated hernia; the analogy, he ob-
serves," is striking and illustrative." Surely when too large
an head is the cause in the first, fatality can be prevented
only, by emptying it of the contents, in the next the same,
and in the last also ; the contents of the two last en-
crease momentarily in pungency, still further requiring
exit. About two years back, I removed a recent strangu-
lation, by gently pressing out the contents, instant re-
lief followed ; Mr. Graves, an experienced Apothecary,

9
was present, and felt the flaccid gut outside, after which
it returned. In another case, attended with violent symp-
toms for many hours, Dr. M.Kever, who was educated a
Surgeon, witnessed the same. On the 3d of November
last, an elderly female laboured under strangulation at
the navel about 50 hours, which resisted the usual treat-
ment, vomiting, foetid matter, was constant; a gentle
effort by the taxis gave great pain, and operation by the
knife seemed the only remedy. Mr. M‘Dowel saw her
early in the morning first time: I met him and Mr.
Adams at mid-day, both Surgeons of the best acquire-
ments; I removed the strangulation in their presence,
as in the other cases, in about 15 minutes, on the contents
receding, the pain abated; after a few hours a fætid
stool passed, and recovery was complete, the pain attend-
ing the successful attempt was trifliog.
The authorities, arguments, and facts stated, I hope
will convince Sir A. Cooper, that the principle and prac-
tice he impugns, are better founded than he imagined,
and that if, as he observed, he suffers such a calamity,
which I hope may never happen, he will avoid the prac-
tice he proposes for himself, namely, in the first instance
the taxis for about 15 minutes, then bleeding, tobacco
enema, and if they fail, operation speedily, and that
he will reverse the order of proceeding, and defer the
taxis until bleeding and the enema had been used, then
danger from handling will be lessened, and we know that
the taxis encreases inflammation when it fails; he would
be still safer, I am satisfied, were cold applied first for
an hour, it evidently controls inflammatory action,
and abates sensibility, very material preparation for ma-
nipulation, and for the ulterior operation. When cold

10
succeeds the tumefaction disappears as per saltem with (a
hissing noise caused by exit of the contents,) not paulla-
tim as the fingers are erroneously employed to accom-
plish. It is evident that the crudite Monro and Huxham,
held the theory, I maintain, as to distension by air,
the use of cold, &c. and that John Bell, whose works
evince the visus eruditus in a degree equalled by very
few, having strongly marked the analogy between stran-
gulated hernia and other ailments which were curable only
on the principle I advocate, supports my practice, and
all are opposed on these points to Sir A. Cooper, whose
labours I respect, and whose character I highly esteem.
To the zeal and sagacity of Dr. Bishop, the cause of
humanity and science are deeply indebted, for discover-
ing, and ardently investigating, a valuable and instructive
fact, which must light the way to improved treatment
hitherto unsuccessfully advocated by me. Dr. Bishop
treated the case in the most approved manner, and like
the scientific mariner, found and marked the rock to be
avoided. For a fuller explanation of my views of the
disease and plan of treatment, I refer to my pamphlet,
requesting indulgence for the manner, but not for the
matter; the former betrays carelessness and haste, the lat-
ter is the result of much observation and reflection: I
have defended it in the Edinburgh Medical Journal, 7th
vol. 1811, which article I annex, as it shews much of
my
original views and treatment; am desirous that the argu-
ment be patiently examined, as it has been generally ob-
jected to, but never refuted; it is on practical points I
insist, which it were unfeeling to suppress, where diff-
culty and danger só imminently prevail; they are it
appears, at variance with the course advised by our

11
ablest practitioners, but I am satisfied that they are
based on sound principles, and must altimately prevail.
* In the original publication I have quoted verbatim
the advice of Munro, Pott, Bell, Cooper, and Law-
rence, on the taxis in strangulated hernia, a manipulation
as described by them, in my judgment not adapted to the
cnre of the disease on principle, and calculated to aggra-
vate it, to a dangerous extent, indeed so as to occasion
the obliteration we have been discussing.
I am,
With high respect and regard,
Your obedient Servant,
EDWARD GEOGHEGAN,
Dullin. 1826.
a
* The following experiment will shew how the taxis works :-Put a fold
of intestine through a ring-inflate it, and impede the circulation of the
contained fluid. In this state press it in any direction, and yield as it will,
the bulk must remain the same, and hinder its passing through the ring
whilst the air is confined, and every impulsion by the hand will occasion
pressure, and rather overlapping at the ring than passage through it, but
diminish it by renoving the air, and all difficulty will be removed,
Nee danut Miruh 1520. Kordon Med?
Ve
Senden
Gazette soos
Preporus
which Semogaj astroente tu kathers
follaccins, cent?
sectors
practice


From Edinburgh Journal,
1811.
a
A gentleman, advanced in years, who had a reducible
hernia 30 years, was suddenly seized with the symptoms
of strangulation whilst walking the street. After about
two hours I saw him. There was a large portion of in-
testine in the scrotum, aud great tension and pain at the
ring. I endeavoured, by the application of cold water
and ice, to lessen the size of the tumefied parts, avoiding
the taxis. Having pursued this plan an hour without
success, and finding that the sensibility of the part had
decreased, I then made a trial with my hands to press
out the contents, but their passage was interrupted. The
general distress increasing, eight ounces of blood were
taken from the arm, a purgative glyster was administer-
ed, and, after some fæces were discharged, a weak in-
fusion of tobacco, to which langour succeeded. In this
state I applied the hands, and was surprised at not feel-
ing the testicle on that side: the patient informed me
that it had never descended so low as the other, was
much smaller, and had sometimes ascended into the
belly, particularly when returning his hernia. Oa a mi-

14
nute examination I discorered the testis as a plug in the
aperture, by its pressure closing up the intestinal tube,
and impeding the circulation through it, thus producing
the strangulation. I endeavoured to remove the testis,
but failed. The pulse having increased in frequency
and hardness, four ounces of blood were taken away,
which was succeeded by an abatement of the pain, and
greater regularity of pulse. Despairing of being able to
remove the obstructing cause without exposing the parts,
I proposed the operation, to which consent was refused.
I directed all my efforts towards dislodging the testis,
which at length succeeded: the hernia became diminish-
ed in size, and the strangulation yielded. This took
place on the third morning after the attack.
In April, 1811, I was called upon to see a female, who
was seized about six hours before with strangulated
hernia; she was young and robust. I took blood from
her arm until she swooned, and put in practice the
usual means, of which I approve, but unsuccessfully.
She resisted the operation until the fourth day; in the
interim she lost about fifty ounces of blood. On laying
the sac bare, it was gangrenous and readily broken in
threads by a director; the intestine was chocolate co-
loured. These appearances, and the length of time the
disease had continued, inclined me almost to despair of
success. I incised the tendon about one eighth of an
inch, within about half an inch of the pubes, grasped
the intestine between my fingers and thumb, gently press-
ed its sides together, until it was emptied; it then re-
turned with the greatest ease, and she recovered.
I am induced to communicate the first case on account
of its singularity; also as affordiug an instance in which

15
strangulation was produced, independent of the aperture,
by the mechanical pressure of an adventitious body, and
in which the practice I oppose was contra-indicated :
all attempts in the usual way would have increased the
mischief: It clearly illustrates the rationale contended
for in my late publication : namely, that the indication
of cure was not the return into the abdomen of the pro-
truded parts, by pressing them up with the hands in the
direction of the aperture ; that the apertures were pas-
sive, and only secondarily concerned, and that a pervious
state of the intestinal tube, and abatement of inflamma-
tion, were the sole indications, requiring for their fulfil-
ment a manual effort totally different from that which is
laid down, and of which they strongly mark the impro-
priety.* I introduced the next case to shew the advan-
tage of copious bleeding: to which I attribute in a great
measure the successful termination. That such a subject
should have escaped diffused inflammation, and its con-
sequences, during four days that she suffered under fe-
meral hernia, by far the most dangerous kind, on account
of the smallness of the aperture, is scarcely to be con-
ceived. It also exemplifies the manner of treating the
intestine (after being exposed in the operation,) which I
advise; I held it within my fingers and thumb until it
became flaccid, without any view to replacing it in the
tamefied state. The universal practice is, after cutting
the tendon, to endeavour to return the gut; and if it is
too large for the opening, to dilate still further until the
aperture admits of its easy return. Now, there is a wide
difference between returning a tumefied and a flaccid
intestine; the former will require a large incision, the
* Mr. Hartigan saw both these patients on consultation. On my
stating the first case, he judiciously remarked, that the general practice
of pushing up would be improper here; that we should pull down.

16
latter a small one, which is a point of great moment.
Were it granted as I contend, that to effect the return
of the contained air was sufficient, a large incision would
never be deemed necessary in mere intestinal hernia;
the slightest increase of space would admit of its escape.
I have seen this operation performed by Surgeons who
were considered as dexterous, and they always pushed
the hernia towards the opening, and if its entrance was
impeded, they enlarged the incision, and exerted consi-
derable force to effect its replacement; and the event
often proved fatal. About eight months ago, I saw a
Surgeon of great experience perform the operation. As
he pressed the intestine towards the opening, it slipped
in all directions through his fingers. After enlarging the
incision twice, he was still foiled in his attempts; at length
he applied both hands, raised himself on his toes, and,
bringing to bear all the force he could exert, drove the
inflamed bowel before him. Now, after the tendon had
been freely cut, the tumefied state must have been kept
up by stricture further in, or the agglutination of the in-
testine, which had taken place during the strangulation,
must have continued; in either case, the resistance was
in the impelled body itself, whilst it continued, and until
it was removed, the return of the hernią ought not to
have been attempted.
In endeavouring to relieve strangulated hernia, I con-
tend that theory and practice correspond in support
of the opinion I have advanced, as to the indication of
cure, and the manner of carrying it into effect. In fur-
ther illustration I shall suppose a case of ordinary occur-
A hernia shall remain displaced a length of time
without any ill consequence : on a sudden it shall suffer
rence.

17
external violence, or from bodily exertion an increased
quantity will rush down; it becomes enlarged, and vio-
lent symptoms ensue; Nothing can be more clear than
that these symptoms were not produced by the displace.
ment, and of course that the cure does not consist in the
replacement. No: the strangulation is a new disease,
which has supervened upon the protruded parts, and,
agreeably to a settled principle of the ars medendi, the
supervening disease is always to be removed first. The
removal of the original is an after consideration, and may
require distinct means; this is a distinction of the first
importance, essential to ground a rational practice upon.
Inflammation has supervened upon a part of tubular
structure, and it should be borne in recollection that it is
double, and forms as it were two tubes within a small
opening; the natural contents are air and fluid fæces;
these tubes become obstructed, hence inflation and im-
peded circulation. The remedy for this state surely is
the removal of the inflammation and tubular obstruction,
because previously to their occurrence there was no
strangulation, although the intestine was PROTRUDED.
How can we then reconcile the established opinion, that
the indication of cure, nay the very first indication, (ac-
,
cording to Sir A. Cooper,) is to replace in the abdomen
(where it might not have been for months before) this
inflamed mass; to effect this by pushing it forcibly
through the aperture, which is already too confined to
contain its smallest part? One would think that an her-
nia, which lay at ease in the scrotum for some time,
would not require to be forced out of its situation, to re-
lieve an inflammatory attack upon it. In pressing up
this inflated and folded tumour from the bottom, surely
it will divaricate as much as the sac will allow, which

18
will weaken its force, and in every step oppose the in-
tention, besides the mischief to be dreaded from the re-
sistance of tendinous parts, and, in femoral hernia, of
the bone. Was the indication correct, the bulk of the
hernia must prevent its fulfilment. Herniæ of small size
are sometimes exceptions to this, but by no means proof
of the efficacy of the practice; in many such instances
the indication has been fulfilled, yet the termination was
fatal, and the hernia has been found within the abdomen
still strangulated. There is a case in the Philosophical
Magazine for September, 1810, (which although not the
same, is in point,) by Mr. Taunton, in which an hernia
was with great difficulty pushed inside the abdominal
ring; the symptoms continued, and it proved fatal. On
examination it was found situated on the anterior part of
the spermatic process, between the peritoneum and abdo-
,
minal muscles, still strangulated, not by the apertures,
but by the peritoneum. All the viscera were in a healthy
state ; from which Mr. T. infers, that if an operation had
been performed early, the life of the patient might have
been preserved; to which I beg to add, that if the sur-
geon had not attempted to fulfil the indication of re-
placing the gut, it would have been visible and tangible,
and have invited the operation; and had he endeavoured
merely to squeeze out the contents in the way I pro-
posed, without pushing it back in its tumefied state, and
did not succeed in emptying it, the fallacy to which the
death must be attributed could not have occurred. The
records of practice, and the experience of several sur-
geons furnish examples to the same effect; still the latest
writers and teachers recommend this very practice, unin-
structed by these facts, and merely copying those that
went before. The reasoning and facts advanced in this

19
paper, and in my publication, and much observation,
perfectly satisfy me, that the indication of cure, and the
manner of fulfilling it, as univerfally taught, are at va-
riance with all principle, not adapted to the cure, highly
dangerous, and ought to be abandoned, and the indication
substituted of abating inflammation, and removing tubular
obstruction, which is often effected by local and general
remedies, as I have already detailed, without handling the
part, and should they prove ineffectual, the sensibility
will be lessened so as to admit of manual efforts with more
safety. These efforts should be conducted differently
from the usual manner, their object being different,
namely, the return of the contents of the hernia, not the
hernia itself. This is to be effected by embracing it with
the hand or hands, according to its size, and gently
squeezing, so as to act upon the contents without dis-
turbing the hernia much, or removing it from its situa-
tion. If the contents obtain exit through the obstructed
part of the intestine, the strangulation will yield; then the
intestine being reduced to a smaller size than the aper-
ture, can be replaced with ease: It is manifestly its bulk
that constitutes the resistance; a point of incalculable
importance on which to anchor. Should this practice
fail, the hernia will still be within the reach of operation,
and those fatal consequences arising from strangulation
within the ring, after the replacement, can never occur.
Every practitioner lays great stress on the direction
which ought to be given to the pressure; but this cannot
be necessary to press out the contents, because a confined
fluid will force its way where there is the least resistance,
and it is best assisted by the gradual approximation of the
sides of the containing tube. Surely when the disease

20
yields to the tobacco glyster, and to cold applications, the
contents must have passed without any direction having
been given to them, or force of any kind used. In femo-
ral hernia I cannot too strongly mark the danger of the
usual practice, as the inflamed gut must be greatly con-
tused by pressing it against the bone, (which surely can-
not yield,), and against the sharp edge of the tendon. I
have heard a professor, in recommending his pupils to use
force, state, that the objects of returning the hernia, and
of pressing out the contents, may be effected together; but
this opinion cannot be supported a moment: because,
as it is intended to overcome the resistance which the
apertures afford, the gut should preserve its firmness all
through, for the moment the air is pressed out, it becomes
flaccid and totally unfit for the intended purpose; he
should desire, on the contrary, that the sides of the intes-
tine be firmly agglutinated, and not a particle of the con-
tents escape, so as to be wielded like a wedge in forcing
through these rigid parts. He also observed, that when
the operation is performing, it sometimes happens, that
in returning the hernia, it pushes out, and there is great
difficulty in retaining the part first returned within the
carity. To remedy this, he directs, that, after pushing
up a part, the fingers should be placed at the aperture,
to keep it in, whilst the other hand was employed in pres-
sing up the remainder. That this view of the case, and
the practice, are erroneous, I conceive can be easily
shown. The inflated state is not attended to; protrusion
is the natural effect of the continuance of that state; the
removal, then, of the air, &c. into the part of the gut
which is within, by gentle pressure, will render it flaccid ;
then its pervious state will be ascertained, and it will not
protrude until there is time to finish the operation. It is

21
also recommended to draw down part of the gut after the
incision of the tendon ; in favour of which practice no
good reason is advanced, and it is liable to strong objec-
tions. It is tumified and inflamed outside and inside the
apertures, and contused at the point of pressure; in this
state it is to be stretched and pulled through a tense small
opening, resisted within by tumefaction, and all this to as-
sist its return into the abdomen. Now, if a pervious state
of the gut and freedom of circulation have taken place,
the slightest pressure will reduce the size of the hernia
smaller than the opening, and in that state all resistance
will be removed, and it can be passed in with the great-
est ease.
To conclude, I request I may be understood as op-
posing the principle, that strangulated hernia is to be
cured by pushing back, by force, the inflamed and in-
flated parts through the perforations in the abdomen; as
desirous of deciding the question of bleeding quoad
vires, which is in doubt, and establishing the principle,
that inflammation alone is to be combated, with reference
to the importance of the parts, and the necessity of im-
mediate alleviation. In the opinion that the term
strangulated is not expressive of the real nature of the
disease, and encourages the practice which I think er-
roneous, I would substitute the term inflamed hernia.
We know that patients under enteritis have precisely the
same feelings and effects as those who labour under in-
flamed hernia, yet there is no stricture from tendinous
compression, in the former; the intestines are inflamed,
and the distress arises from their being distended with
flatus of the moss pungent kind in the inflamed state.
In inflamed hernia the effect from the apertures is inci-

22
dental, which is proved by the existence of the disease
when they are perfectly free. Dissections shew that the
cause of death in both diseases is the same; namely,
diffused inflammation and its consequences. The sur-
geon who is impressed with the notion, that he is to cure
inflamed hernia, will never place his patient on his head,
and toss him about; such practice may increase, but
cannot abate the tumefaction, which is the sine qua non;
;
he will not attempt to push it by foree throngh an aper-
ture which bears no proportion to its dimension. No:
he will proceed as in all cases of visceral inflammation,
enjoin composure, and hold firmly in his view, that
UNTIL THE OBSTRUCTION IN THE INTESTINE, which is the
effect of inflammation, is removed, its replacement will
not cure, and ought not to be attempted, He will re-
turn the hernia after the inflammatory stage, when it can
be done with safety, as curative of hernia, but not of
strangulation, as it is termed. That the operation has
very often terminated fatally, although less frequently
than formerly, must be acknowledged. The cause as-
signed for this termination has generally been, that it was
performed too late, to which I assent, in a great measure ;
but I particularly attribute it to a mistaken view of the
disease, and the practice founded upon that view. It is re-
presented as if entangled, and to be disengaged by jolting
the entire body, and forcing with the finger and entire
band, &c. &c, which is by no means calculated to remove
the contents (although it does so sometimes per accident)
and must aggravate the symptoms so as to render future
operation unavailing. I consider the jolting as improper
as it would be in enteritis. The French surgeons succeed
more frequently than we do, which is attributed to ope-
rating early: I attribute their success to bleeding, which

23
they carry to great extent, and to their avoiding manual
efforts very much. Desault forbid them altogether; in-
deed their chief reliance is on bleeding. The many cases
recorded, my own experience and view of the disease,
warrant me in believing, that if the hands were not ap-
plied, but strict attention paid to composure and posi-
tion, and bleeding particularly attended to, that the ope-
ration would be less frequently necessary and oftener
successful. I conduct the manipulation in the manner an
elastic bottle or a bladder is emptied when administering
an enema. It is last in my order of treatment before the
knife; first with every one else. The representation of
all our modern writers, that the gut is girt as if bound
by a cord, strongly opposes their own practice, as to the
taxis, by supposing an immoveable state, which every
touch of the fingers must inflame, and still further en-
large, whilst the indication is to diminish.
.
To the attemps which have been made to decry my
opinions, I offer these reflections in reply; desirous of
defending myself only by further explanation, scorning
the example of those reviewers who degrade an honoura-
ble profession by illiberality, and, instead of elucidating
science by temperate discussion, obscure it by misquota-
tion, and every kind of misrepresentation; thus disgust-
ing the ingenuous, repressing their zeal, and discourage
ing their contributions; to the prejudice of humanity.

lo
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