ARTES LIBRARY VERITAS SCIENTIA OF THE UNIVERSITY OF MICHIGAN LU VE FITTE TCEBOR 41-QUERIS PENINSULAM AMENAM CIRCUMSPICE The George E. Wantz (UM Medicine 1946) Collection A TREATISE ON HERNI A. T A TREATISE ON HERNIA: BEING The Essay, WHICH GAINED THE PRIZE OFFERED BY THE ROYAL COLLEGE OF SURGEONS IN THE YEAR 1806 ILLUSTRATED WITH PLATES. BY WILLIAM LAWRENCE, MEMBER OF THAT COLLEGE; AND DEMONSTRATOR OF ANATOMY AT ST. BARTHOLOMEW'S HOSPITAL. "Tout praticien peut à la vérité remarquer quelques faits extraordinaires, acquérir par l'exercice de son art quelques connoissances intéressantes, inventer quelques moyens particuliers dont on n'a point encore parlé; et ce sont ces mêmes nouveautés qui enrichissent peu-à-peu l'art de guérir. Mais cette ex- perience propre à chacun n'est qu'un point, en comparaison de l'expérience générale qui s'est formée par le concours des découvertes et des observations qui nous ont été transmises par une multitude de praticiens qui ont vécu en différens tems et en différens lieux." HEVIN in the Mémoires de l'Acad. Roy. de Chirurgie, tom. I. p. 500. London: PRINTED FOR J. CALLOW, MEDICAL BOOKSELLER, CROWN COURT, PRINCES STREET, SOHO, BY G. HAYDEN, BRYDGES STREET, COVENT GARDEN. 1807. TAUB RD 621 L38 Cop. 1 TO JOHN ABERNETHY, Esq. F. R. S. TEACHER OF ANATOMY AND SURGERY, ASSISTANT SURGEON TO ST. BARTHOLOMEW'S HOSPITAL, HONORARY MEMBER OF THE ROYAL MEDICAL SOCIETY OF EDINBURGH, &c. &c. DEAR SIR, I embrace, with great pleasure, the opportunity afforded me, by the publica- tion of the present work, of publicly ac- knowledging the kind advice and valuable instruction which I received from you, in the direction of my professional education; and the friendly and liberal behaviour, which I constantly experienced under your roof. To these motives, which are of a private and personal nature, I will take the liberty of a 3 vi DEDICATION. adding the public considerations which in- duce me to prefix your name to these pages. I allude to the numerous and well-known improvements, for which the Science of Sur- gery is indebted to your genius and industry, and to the very honourable and independent principles, which regulate your conduct in the practice of a truly useful and liberal profession. With unalterable sentiments of respect and esteem for your public and pri- vate character, I remain, Dear Sir, Your obliged and Most faithful Servant, WILLIAM LAWRENCE. PREFACE. THE subject of Hernia affords a more ex- tensive field of discussion than any other single affection that occurs within the sur- gical department of the healing art. The numerous situations in which ruptures may occur, the variety of their contents, and the very different states in which the contained parts are found, occasion so many modifi- cations of the description and treatment of the complaint, that a consideration of the subject in all it's details, instead of furnish- ing an essay of the length, which custom viii PREFACE. has prescribed on such occasions, as that which gave rise to the present work, would afford ample matter for a large volume. Hence it cannot have been in the contem- plation of the College, that the competitors for their prize should exhibit a complete history of Hernia. The general description of the symptoms and progress of the com- plaint is given with sufficient accuracy in most systematic writers, and the valuable works of POTT and RICHTER* have so ex- hausted the subject, that I shall be readily excused for passing it over as briefly as pos- sible. The treatise of Mr. PoTT is more- over so particularly distinguished by that lucid arrangement, accurate description, and elegant style, which adorn all his writings, that a person, who should take up the subject *Von den Brüchen, 2 vol. 8vo. Göttingen, 1778 and 1779. A French translation of this work has been published at Bonn, in 1 vol. 4to. under the title of Traité des Hernies de Mr. A. G. Richter, by ROUGEMONT, the professor of anatomy and surgery at that place. PREFACE. ix after him, would, besides losing his labour, expose himself to the risk of a degrading comparison. The College have pointed out, as the particular object of their prize essay, what will be allowed by every one to be the most important part of the subject; viz. The Treatment of Hernia. On this therefore I shall enter at large. I propose also to consider, at some length, the anatomy of the parts concerned in inguinal and femoral hernia, because these points have been ge- nerally passed over very lightly in surgical books, and have received, only of late, that share of attention, which their great impor- tance entitles them to. This plan excludes the consideration of the more rare species of ruptures, which, indeed, fall so seldom under the observation of an individual, that he would be obliged to recur, for his de- scription, to the writings of others; and it will justify me in omitting entirely, or con- X PREFACE. sidering very cursorily, such points as do not demand a more detailed discussion. The copiousness of the subject, and the necessity of confining the work within cer- tain limits, induced me to compress the observations, which I had the honour of submitting to the College last year, into as small a compass as possible, and to pass over many points in entire silence. As the same motive of restraint does not exist on the present occasion, I have enlarged the original essay, so as to exhibit a view of every thing, which I consider it necessary for the surgeon to be acquainted with, con- cerning the four most frequent species of the complaint; viz. the Inguinal, Crural, Umbilical, and Congenital Ruptures. As it seems to me, to be an indispensable part of such a plan, to notice the labours of preceding writers, and to make use of the facts which they have recorded, I think it unnecessary to offer any apology for the PREFACE. xi. quotations which appear in the following pages. The view which a surgical writer would give of any subject, from his own observation only, must necessarily be par- tial and confined: it will be corrected and improved by comparing it with the result of general experience. I doubt, indeed, whether it would be possible for a person, well-acquainted with the writings of others, to give an account of any extensive surgical subject entirely uninfluenced by the facts or reasonings contained in their works: I think it certain, if he could accomplish this object, that the utility of his labours would be much diminished. CONTENTS. CHAP. I. Description of hernia-causes-symptoms of the complaint in it's various states-prog- nosis, &c. SECT. 1. General description of hernia, and enumeration of the most important species 2. Causes of hernia PAGE 1 3 35 3. Symptoms of reducible hernia 12 4. Symptoms of strangulated hernia 16 5. Different species of strangulation 22 6. Prognosis of strangulated hernia 28 CHAP. II. Treatment of reducible hernia Construction and use of trusses CHAP. III. 33 36 Treatment of irreducible hernia - - 49 CONTENTS. xiii CHAP. IV. PAGE Treatment of strangulated herniu SECT. 1. The taxis -54 56 2. Bloodletting 67 3. Purgatives 73 4. Tobacco glyster 76 5. Antispasmodics 81 6. Cold-bath and cold applications 83 7. Warm applications - 85 - 86 8. General observations CHAP. V. Anatomy and symptoms of inguinal hernia SECT. 1. Anatomical description of the in- guinal hernia Course of the epigastric artery Hernial sac - 2. Symptoms of inguinal hernia 94 ibid. 105 110 118 CHAP. VI. Operation for strangulated inguinal hernia 122 ibid. 127 SECT. 1. Exposing and opening the hernial sac 2. Incision of the stricture SECT. 3. Wounds of the epigastric artery 138 4. Incision of the tendon without including the neck of the sac - 143 XIV CONTENTS. 5. Replacement of the protruded. parts 6. Treatment after the operation 7. Proceedings designed to promote the radical cure 8. Mode of operating on large herniæ 9. Operation where the tumour has PAGE 149 - 155 o 158 160 166 not passed the ring CHAP. VII. Treatment of the omentum 167 CHAP. VIII. 183 ibid. - 186 - 197 205 Treatment of hernia, when the intestine has mortified 1 SECT. 1. Symptoms of mortification and prognosis 2. Treatment where a small spot only has mortified 3. Mortification of the whole di- ameter of the intestine 4. Artificial anus CHAP. IX. Symptoms, anatomical description, and treat- ment of femoral hernia Symptoms of femoral hernia 214 ibid. CONTENTS. XV Anatomy of PAGE 218 Strangulated 236 Reduction of 243 Operation of 244 CHAP. X. On umbilical hernia 258 261 GND 267 272 290 292 Sac of umbilical hernia SECT. 1. Congenital umbilical hernia 2. Umbilical hernia in young sub- jects 3. Umbilical hernia in the adult Operation for umbilical hernia CHAP. XI. On congenital hernia APPENDIX. Containing some further particulars of the case of artificial anus, represent- ed in Plate III. Explanation of the plates 295 311 315 TREATISE ON HERNIA. CHAPTER I. DESCRIPTION OF HERNIA CAUSES - SYMP- TOMS OF THE COMPLAINT IN ITS VARIOUS STATES-PROGNOSIS, &c. IF there be any disorder, which, from the frequency of its occurrence, and from the variety of forms, under which it is presented to the care of the surgeon, demands more than others his most minute and attentive investigation, in every part of its history and treatment; such, assuredly, is that which forms the subject of the following pages. Surgeons of great experience in the treat- ment of ruptures have estimated, that one- B GENERAL DESCRIPTION eighth, or one-sixteenth of the human race is afflicted with this complaint; which af- fects, indiscriminately, persons of both sexes, of every age, condition, and mode of life. It is true, indeed, that a hernia, if properly managed, is not immediately dangerous to the patient; does not affect his health, nor materially diminish his enjoyments: but it is a source of constant danger, since any violent exercise or sudden exertion may bring it from a perfectly harmless state into a condition, which very frequently proves fatal. The numerous situations in which rup- tures may occur, the disorders with which they may be confounded, the very different states in which their contents exist, and the minute anatomical knowledge required in operating on them, bestow a peculiar im- portance on the subject, and require to be studied with the most anxious interest by every man, who wishes to practise his pro- fession with honor to himself, and advantage to his patient. OF HERNIA. 3 SECTION I. General Description of Hernia, and Enume- ration of the most important Species. THE passage of any of the abdominal vis- cera, from the cavity in which they are naturally contained, into a preternatural bag, formed by the protrusion of the peri- toneum, constitutes a hernia, or rupture, according to the most common acceptation of these terms. The protruded portion of the peritoneum is called the hernial sac. For the more particular description of this part, which is a subject of great importance, I refer the reader to the chapter on the anatomy of inguinal hernia. A hernia generally causes an external tu- mour, which is named, either according to its situation in the body, or from the parts which it contains. The groin, scrotum, labia pudendi, bend of the thigh, and navel, are the most frequent seats of these swel- B2 4 GENERAL DESCRIPTION lings; the omentum and intestines their most common contents. When the protruded viscera have de- scended through the abdominal ring, with- out passing further than the groin; or when they are contained in the labium of the female, the case is called a bubonocele, or inguinal hernia: when they have passed into the scrotum, it is termed an oscheocele, or scrotal rupture; and if they are in con- tact with the testis, it is distinguished by the epithet congenital. The crural, or femoral hernia, is that which takes place under Pau- part's ligament; and the exomphalos, or um- bilical rupture occurs at the navel. The names enterocele and epiplocele, which are equivalent to intestinal and omental rup- ture, are employed according as the swelling contains intestine or omentum alone: where both these parts are found in the same tu- mour, it forms an entero-epiplocele. These, which are by far the most frequent forms of the complaint, are all that I pro- pose to treat of in the present Work. So long as the viscera descend and return freely, the complaint is said to be in a re- ducible state. When, after long residence OF HERNIA. 5 in the tumour, they have either increased so much in bulk, or have contracted such adhesions to each other, or to the hernial sac, as to become incapable of being re- turned, although they experience no pres- sure from the ring, it is termed irreducible. An incapacity of reduction, arising from stricture in the opening through which the viscera have descended, brings the disease into the strangulated or incarcerated state. SECT. II. Causes of Hernia. THE causes of herniæ may be referred in general to two divisions, according as they appear to operate by increasing the pressure of the viscera, or by diminishing the resist- ance of the abdominal parietes. The former may be ranked, in a systematic arrangement of the subject, as occasional or exciting; the latter as predisposing causes of the com- plaint. Alternate contractions of the diaphragm and abdominal muscles are among the chief 6 CAUSES agents in the important function of respira- tion. The gentle pressure, which the vis- cera constantly receive from this source, becomes greatly augmented by any unusual exertion, which is always attended with a forcible action of both these powers at the same time. When such efforts are carried beyond a certain point, the parietes of the cavity give way to the impelling power, at those parts where they are weakened by the holes for the transmission of blood ves- sels, and the viscera are thrust forth from their situation, carrying before them a por- tion of the peritoneum, which forms the hernial sac. Thus it is that ruptures are frequently produced by the act of lifting or carrying a heavy weight, in running or jumping; in short, under any circumstances where the strength is forcibly exerted. On this principle we can account for the obser- vation concerning the greater frequency of ruptures among the inhabitants of moun- tainous countries;* with whom opportuni- * BLUMENBACH has observed this with respect to the Swiss, and to the inhabitants of the Alps in general. RICHTER, Chirurgische Bibliothek. b. 8. OF HERNIA. 7 ties must frequently occur of exerting their strength and activity. Other causes, referrible to the same head, arise from the forcible action of the respi- ratory muscles in the expulsion, of the con- tents of the viscera. Vomiting, straining at stool, and the act of parturition often pro- duce ruptures. In strictured patients I have seen herniæ formed gradually in consequence of the habitual efforts required for the eva- cuation of the bladder. Crying is a frequent source of the complaint in children. The predisposing cause of ruptures has been referred to a naturally greater size of the openings at which they protrude; to a weakness and relaxation of the margins of these apertures; and to a preternatural laxity of the peritoneum. The former circum- stance has probably a chief operation; since in males, where the abdominal ring is na- turally capacious, inguinal herniæ occur in a very large proportion, while the femoral species is very rare; females on the con- trary, having the capacities of these aper- tures reversed, are seldom affected with inguinal ruptures, Without, however, at- 8 CAUSES tempting to decide what is the true reason, it may be safely asserted, that particular subjects manifest an unquestionable dispo- sition to the complaint. In such persons a very slight occasional cause, such as the act of coughing or sneezing, will bring on a rupture; the complaint, indeed, appears sometimes spontaneously. "I know," says Richter,* "a savant, who leads a sedentary life, and in "whom an inguinal hernia appeared sud- denly some time ago. I applied a ban- 66 66 966 dage, and in a few weeks a similar hernia "came on the opposite side; a bandage was applied to this also; and in a very short " time a crural hernia made its appearance. "I have seen several similar cases; and "have known four or even five herniæ come " in the same subject, without the least oc- "casional cause." When it is stated that hernia has some- times appeared to be hereditary, the mean- ing of the observation must be, that there is a certain weakness in the original forma- tion of the parts, predisposing to the com- *Traité des Hernies, p. 9. OF HERNIA. 9 4 plaint, and that this defect may descend to the offspring; and in this sense its truth cannot be disputed. I believe that the word hereditary, in its application to disease, has been always used according to this inter- pretation; and that the employment of it in its strict sense has only been suggested by those, who wished to shew their inge- nuity in refuting an absurdity of their own creation. The dilatation of the openings, through which herniæ take place, in consequence of the distention of the abdominal parietes during pregnancy, accounts for the greater frequency of ruptures in general, and of the exomphalos in particular, in women who have borne children. The ruptures which appear after debili- tating diseases, and those which occur in persons, who, from a state of corpulency, become suddenly emaciated, must be refer- red to weakness. 10 CAUSES CASE. A friend of mine met with a remarkable instance of the latter kind in a French emi- grant. The danger, anxiety, and fatigue which this unfortunate gentleman experi- enced in escaping from his native country, and the extreme indigence, to which he found himself reduced on his arrival in Eng- land, reduced him from the embonpoint, which the luxurious table of affluence had produced, to a state of considerable ema- ciation; and a hernia took place at each groin.i We are sometimes unable to determine what is the direct cause of the rupture; as, where it happens in consequence of a blow, from the agitation of a rough cart, or vio- lent horse exercise. The latter circum- stance has certainly a decided influence in producing the complaint; for cavalry are found to be ruptured in a much greater proportion than foot soldiers.ro OF HERNIA. 11 It would be useless to make a point of enumerating every trivial circumstance which may occasionally contribute to the formation of a rupture. The general view, which I have already given, will enable the reader to understand the subject sufficient- ly. I shall just observe, that some of the causes, assigned by systematic writers, are totally inadequate and even ridiculous. In the respectable work of RICHTER, which de- serves on the whole much commendation, the origin of hernia is attributed to the use of relaxing and aqueous liquors, of fat and oily kinds of food; to moisture of the cli- mate, &c. Hernia, which originate in predisposi- tion, generally come on gradually, and al- most imperceptibly; while those, which are produced by bodily exertion, are formed suddenly, and by the immediate action of the exciting cause. The occurrence of the complaint is often indicated in the first in- stance by a fulness, combined with a sense of weakness about the abdominal ring. The swelling is increased by any action of the respiratory muscles, and disappears on pres- 12 SYMPTOMS OF sure, and in the recumbent position of the body. It gradually finds its way through the tendon of the external oblique muscle into the groin, and afterwards into the scro- tum. When a hernia takes place suddenly, it is generally attended with a sensation of something giving way at the part, and with pain. SECT. III. Symptoms of reducible Hernia. WHEN the contents of a rupture experi- ence no pressure from the margins of the opening, through which they have de- scended, their functions are little, if at all impeded; the description of the disease consists therefore chiefly in an enumeration of the sensible characters of the tumour. When, on the contrary, the hernia is stran- gulated, the natural offices of the protruded parts are entirely obstructed; hence various dangerous and alarming symptoms ensue, by which the character of the complaint is completely changed. REDUCIBLE HERNIA. 13 If we meet, in any of the usual seats of herniæ, with an indolent tumour, which has arisen under the circumstances generally attending the formation of this complaint, we naturally ascribe its origin to a protrusion of the abdominal viscera. Our suspicion is converted into certainty, if we find that the swelling varies in size; being smaller in the recumbent position, larger in the erect posture, or when the patient holds his breath; diminishing, or entirely disappear- ing by means of pressure, and enlarging again when this pressure has ceased; if it be large and tense after a meal, or when the patient is troubled with wind, soft and small in the morning, before he has taken any food; if, since the commencement of the complaint he has been troubled with any affections, arising from the unnatural situation of the viscera, as colic, constipa- tion or vomiting; if he perceive occasion- ally a rumbling sensation in the tumour, particularly on its return; and lastly, if it become tense when he coughs, so that an impulse is communicated to the hand of the examiner. 14 SYMPTOMS OF The symptoms of the case will generally point out the nature of the contained parts. If the surface of the tumour be uniform; if it be elastic to the touch; if it become tense and enlarged when the patient is troubled with wind, coughs, or holds his breath; if the part return with a peculiar noise, and pass through the opening at once, the con- tents of the swelling are intestine. If the tumour be compressible; if it feel flabby, and uneven on the surface; if it be free from tension, under the circumstances just enumerated; if it return without any noise, and pass up very gradually, the case may be considered an epiplocele. • The circumstances, which have been just enumerated, characterize the complaint so perfectly, that no doubt can exist as to its nature; there can be no fear of confound- ing it with other disorders, if we advert to their origin, progress, and symptoms. The nature of the case is more doubtful, if the swelling be small and deeply seated; if it has arisen gradually; if it be connected with other tumours; if it contain much fluid, and the patient be fat. Here the greatest attention REDUCIBLE HERNIA. 15 of and discernment are required on the part the surgeon; his opinion must be guided rather by the symptoms, than by the cha- racters of the tumour. A reducible hernia, though attended with no immediate danger, occasions great in- convenience to the patient, particularly if it be allowed to increase unrestrained by sur- gical treatment. The portion of intestine or omentum, which has left the abdomen, produces various complaints from its con- nexion with the parts within. From this source of irritation proceed nausea and vo- miting, indigestion and colic. As the vis- cera become accustomed to their unnatural situation, these inconveniences gradually wear away. Still, as the tumour constant- ly increases in size, a large part of the vis- cera is deprived of that pressure and support, which they naturally derive from the respi- ratory muscles; the passage of the food through the alimentary canal becomes dif- ficult and protracted; and hence large rup- tures are almost invariably attended with flatulence and constipation. The opening, 16 SYMPTOMS OF through which the viscera pass out, must subject them to more or less pressure; which will enable us to account for that effusion of fluid into the cavity of the sac, which is generally observed in old ruptures; and for the formation of those adhesions of the parts to each other, and to the hernial sac, which change the case from a reducible swelling, to one which will no longer admit of reduc- tion. SECT. IV. Symptoms of strangulated Hernia. THE first and most immediate effects of such a degree of pressure, as prevents the return of the protruded parts, are an ob- struction to the passage of the intestinal contents, and consequent want of fecal eva- cuations; and a more or less violent in- flammation in the strangulated part. The former symptom will often occur to as great a degree, and will be equally insuperable by purgative medicines, where a portion only STRANGULATED HERNIA. 17 of the diameter of the gut is strangulated,* as where a complete fold of intestine is in- cluded: it even happens occasionally in a mere epiplocele, where no intestine at all is protruded. Hence it must be referred ra- ther to that inflammatory affection of the intestines, which subsists in this complaint, than to the mechanical obstruction of the canal; and must be considered as analogous to the constipation, which prevails in ileus when produced by other causes. The in- flammation of the protruded viscera causes an effusion of fluid into the hernial sac, and adhesions of the parts to each other, and to the containing bag. When it is particularly violent, a layer of coagulable lymph is some- times thrown out on the surface of the in- testine. It terminates at last, unless the stricture be previously removed, in gangrene. These, which we may call the primary ef- fects of the incarceration, are accompanied by other symptoms, arising from disorder * Mémoires de l'Académie de Chirurgie, tom. III. p. 151.-- London Med. Obs. and Enquiries, vol. IV. p. 178 and 355. 18 SYMPTOMS OF of the parts, which sympathise with the hernia. In an incarcerated intestinal rupture, the tumour, which was before indolent, be- comes painful; the pain is most acute at the strictured portion, and extends from that situation over the rest of the swelling and abdomen; these parts becoming at the same time swoln and tense. The evacuations per anum are entirely suppressed, and nausea and vomiting ensue: all the contents of the stomach, and afterwards those of the intes- tines, down to the stricture, being rejected. These symptoms, which often remit for a considerable period, are accompanied by a proportionate derangement of the whole system. There is great anxiety and restless- ness, with a small and hard pulse, and. coldness of the extremities: after a time hiccough supervenes, the pulse becomes so small as to be hardly sensible, the respiration is weak, and the whole body is covered by a cold and clammy sweat. Mortification now takes place; it begins in the contents of the rupture and extends to the contain- ing and neighbouring parts. The degree STRANGULATED HERNIA. 19 and intensity of the symptoms are modified by various circumstances, as the age and strength of the patient, the nature of the strangulation, &c. The duration of the complaint, from its first commencement, to the termination in mortification or death, is also extremely various. An epiplocele is much less liable to strangulation, than an intestinal rup- ture, and its symptoms are milder and slower in their progress. In this variety of the complaint, stools may generally be procured by purgative medicines or glysters. The connexion of the omentum with the stomach induces hiccough and sickness, and although the latter symptom seldom pro- ceeds to stercoraceous vomiting, it exists to a most distressing degree, and particularly characterizes the complaint. The symp- toms are often influenced by the position of of the body, being mitigated by bending, and aggravated by straightening the trunk. An epiplocele is occasionally accompanied with all the dangerous and alarming symp- toms of an intestinal rupture, as insuperable constipation, fecal vomiting, &c. 62 20 SYMPTOMS OF The examination of a patient, who dies while labouring under a strangulated her- nia, discloses such a state of parts as the symptoms just enumerated would naturally lead us to expect. The whole surface of the peritoneum is inflamed, and the intes- tines participate in this disorder, particularly that portion of the canal, which is above the stricture, which is distended consi- derably beyond its natural diameter. The convolutions of the intestinal canal are ag- glutinated by a recent deposition of coagu- lating lymph; streaks of a bright red colour, consisting of an aggregation of minute vessels, cross the intestines in different directions; and spots of gangrene are not unfrequently observed. All these circum- stances shew us most decidedly that the effects caused by strangulation are of the most active inflammatory kind. We must regard the stricture, which the protruded parts experience, as the immediate cause of this disorder. The symptoms of an incarcerated hernia being those, which attend inflammation of the intestine, it becomes, in all cases, a ne- STRANGULATED HERNIA. 21 cessary and important part of the surgeon's duty to discriminate carefully the cause of such affections. Whenever we see a pa- tient labouring under the symptoms above described, we should suspect the existence of a rupture, and make those inquiries and examinations, which such a suspicion would naturally suggest: when, on the contrary, we know that the patient has a rupture, but find that the swelling is free from pain and tension, and has been so from the beginning of the complaint; and more especially if it admit of reduction, we may with reason as- cribe his symptoms to a different origin. Wherever there is room for any doubt as to the nature of the case, an attentive exami- nation of the symptoms; of their mode of accession, nature, and duration; and of the history of the complaint, can scarcely fail to afford sufficient information for the direction of our conduct. 44 22 DIFFERENT SPECIES OF SECT. V. Different Species of Strangulation. Systematic writers have distinguished the causes of incarceration, as consisting either in a diminished capacity of the opening, or in the intrusion of additional parts into the aperture. The absurdity of this distinction is manifest on the most superficial consider- ation; since it is very obvious, that the pre- sence of either of these circumstances im- plies relatively that of the other. A more important distinction arises from the nature and general symptoms of the case; in com- pliance with which, we discriminate be- tween the acute or inflammatory, and the chronic or slow kinds of strangulation. This indeed is highly useful, as it comprehends the characteristic marks of two very diffe- rent cases, and leads to practical discrimi- nation in their treatment. The inflammatory strangulation occurs in young and strong patients; in cases, where STRANGULATION. 23 a rupture is formed suddenly by a great bo- dily exertion; or where, after having been kept up by a truss for a long time, it is suddenly reproduced by any cause of the same description. It is mostly confined to small herniæ, or to such at least as are of a moderate size. Under the circumstances just enumerated, the opening, through which the viscera protrude, is small: the pressure on the protruded parts must con- sequently be great; and hence, in great measure, arises the peculiar character of the case. The symptoms come on suddenly, and their progress is rapid: the swelling is tense and highly painful, particularly at the ring, where the slightest pressure is intole- rable: the abdomen quickly becomes pain- ful, and is tense and elastic to the feel: the constitutional affection partakes of the in- flammatory character. So quickly does the complaint run through its stages in this case, that gangrene has been known to oc- cur in twenty four* hours from the expul- sion of the intestine. *WILMER'S Practical Observations on Hernia, p. 74.- Porr's Treatise on Ruptures, in his works, vol. II. p. 94, edi- 24 DIFFERENT SPECIES OF The slow strangulation takes place in large and old hernia, which have been often protruded and replaced. The contained in- testines are probably rendered somewhat indolent in performing their functions; as patients of this kind are habitually subject to costiveness and intestinal complaints. The contents of the alimentary canal will easily accumulate and be retained in a si- tuation, where they enter the intestine without difficulty, but have their egress obstructed by the force of gravity. The strangulation arising from such an accumu- lation constitutes the case, which has been tion of 1783. The latter writer mentions another instance, in which a bubonocele terminated fatally in less than a day. (ibid. p. 85.) Mr. HEY has twice seen patients die of hernia within twenty-four hours.-(Practical Observations, p. 142.) In a case alluded to by Mr. COOPER, eight hours only elapsed between the occurrence of strangulation and the patient's death. (Anatomy and Surgical Treatment of Inguinal and Congenital Hernice, p. 26. The same author also gives an instance of umbilical hernia, in which the progress to a fatal termination was remarkably rapid. The symptoms were of the most acute and yiolent description: death happened in seventeen hours and a half after strangulation began; and the integuments bad already mortified at one part of the swelling. (Anatomy and Surgical Treatment of Crural and Umbilical Hernia, p. 45.) STRANGULATION. 25 termed by a French writer* "hernie par "engouement des matières." The rupture swells slowly, and becomes heavy and hard. The abdomen enlarges from the accumula- tion of the intestinal contents above the stricture. After some days the swelling becomes painful, and the patient grows feverish but the fever is not considerable, neither are the abdomen or tumour ever so painful and tense, as in the former spe- cies of incarceration. In some cases of this description, a fortnight has elapsed without any considerable morbid alteration having taken place in the protruded parts. LE DRANT operated on the sixteenth day with- out finding the contents of the swelling much altered from their natural appearance; and SAVIARD did the operation with com- plete success on the twenty-second day from the commencement of the incarceration. The differences observable in the two * See a memoir by Mr. GoURSAUD; " sur la différence des causes de l'etranglement des hernies," in the Mémoires de l'Acad. de Chir. tom. IV. + Observations de Chirurgie-Obs. 57. + Nouveau Recueil d'Obs. Chirurg. Obs. 20, p. 112. 26 DIFFERENT SPECIES OF very opposite cases which I have just de- scribed, admit of an easy explanation. In the first, the close pressure of the ring on the prolapsed parts, in a subject prone to inflammation, causes immediately a violent inflammatory derangement of the abdomi- nal viscera. The accumulation of feces, on the other hand, where the parts and the constitution are in a torpid condition, gives to the disorder the characters of a merely mechanical obstruction. As the description is drawn from the most strongly marked cases, we shall sel- dom find the difference between the two kinds of strangulation so clearly expressed. The symptoms indeed are often of such a mixed and indefinite nature, that they might be arranged without impropriety under either of the above species. To the two kinds of strangulation, which I have now described, RICHTER has added a third, under the epithet of spasmodic, which he considers to arise from the action of the external oblique muscle. It does not seem to me that this case is sufficiently characterized, nor that any practical benefit STRANGULATION. 27 can be derived from the distinction. The following passage will shew what symp- toms this author considers as peculiarly denoting the existence of spasm: " La "respiration courte et froide, le ventre "tendu, gonflé, et cependant peu douleu- 66 reux, le froid, et la paleur de la mort, "qu'on remarque au visage, aux extrémi- "tés; l'anxieté, l'agitation, le vomissement, "le hocquet, le pouls petit et serré ne sont "ils pas des preuves manifestes d'une ma- "ladie spasmodique? et ces symptomes "paroissent souvent dans les premieres mo- mens de l'étranglement."* If these are the symptoms of a spasmodic stricture, every rupture which happens may be clas- sed under this description. 66 Some other rare kinds of strangulation have been noticed by surgical authors. It has been produced by preternatural adhe- sions of the parts, by a fissure in the omen- tum;† by various foreign bodies, which had been previously swallowed; by worms, &c. + *Traité des Hernies, p. 53. + Acta Havniensia, vol. I. + RICHTER, Tr. des Hernies, p. 47. 28 PROGNOSIS OF None of these causes could be ascertained previously to an operation, or to the pa- tient's death, and are therefore of no prac- tical importance. SECT. VI. Prognosis of strangulated Hernia. In a case of strangulated hernia, our prog- nosis will be influenced by the cause of the rupture, by the nature of the incarceration, by the size, situation, and contents of the swelling, and by the age and constitution of the patient. A large and old rupture, which seems most formidable on the first view, is in reality attended with much less danger than a small and recent one; and it is more dif- ficult to effect the replacement of a rupture of the latter than of the former description. 44 "I think (says Mr. Hey) it is not a bad general rule, that the smaller the hernia, "the less hope there is of reducing it by Long-continued efforts to re- "the taxis. STRANGULATED HERNIA. 29 "duce a prolapsed intestine are most likely "to succeed in old and large hernias, when no adhesions have taken place."* 66 An old rupture is not readily strangu- lated, and when it falls into this state the danger is not imminent; the distention of the opening, previous to incarceration, has so dilated and weakened the parts, that they can no longer produce a close constriction. In a small and recent case, the dimensions of the aperture are unimpaired, and its sides are unyielding: strangulation takes place easily, and the degree of stricture is always considerable. The danger is greatest, when a rupture is incarcerated at the moment of its forma- tion. Herniæ, which arise spontaneously, and, as it seems, merely from predisposing weakness, seldom become strangulated: the stricture, in such cases, is never close, nor are the symptoms violent, because the parts concerned are weak and relaxed. The opening, through which the parts protrude, is narrower in some situations * Practical Obs. p. 203. 30 PROGNOSIS OF than in others; the progress of the case will therefore be more rapid, and the dan- ger of the patient more urgent. The aper- ture is generally very small in femoral her- nia: this kind of rupture in men, and the bubonocele in women have a particularly narrow entrance. An enterocele is much more hazardous to the patient than an omental rupture; for the parts are more sensible, and the due performance of their functions is more es- sential to the support of life: a strangu- lated epiplocele is indeed seldom fatal. In persons of a robust constitution, and of the adult period of life, the symptoms will partake of the inflammatory character; the ruptures of old subjects are generally of long standing, which, together with the di- minished powers of their system, bestows on the complaint a more languid form. Although the hernia of infants are very rarely strangulated, they are not entirely exempt from this ocurrence. Mr. POTT* saw a child of one year old die of incarce- *Works, vol. II. p. 33. STRANGULATED HERNIA. 31 rated rupture; and GooсH* has recorded an instance, which proceeded even to morti- fication in an infant of ten weeks. CASE. I lately witnessed a successful operation for scrotal hernia, at St. Bartholomew's hospital in a child fourteen months of age. This case, which was under the care of Mr. LONG, afforded an exception to the general rule mentioned by Mr. Porr "that all "those ruptures, which appear in the scro- 66 tum of very young children are conge- "nial." The parts had descended to the bottom of the scrotum, but were not con- tained in the tunica vaginalis testis. All the usual means of reduction had been at- tempted ineffectually, before the operation was resorted to; the contents of the tumour consisted of a portion of large intestine, the sac was very thin, and, though adherent to *Surgery, vol. II. p. 203. + Works, Vol. II. p. 22. 32 PROGNOSIS OF STRANGULATED HERNIA. the surrounding parts, mistaken at first, as it frequently is, for the intestine: the great closeness of the stricture rendered the di- vision of the tendon a matter of some dif- ficulty. The crying of the child forced the gut frequently through the wound in the progress of the cure; but the parts being supported by sticking plaister, gradually. healed. The rupture descended again in a short time. TREATMENT OF REDUCIBLE HERNIA. 33 CHAP. II. mabiode. TREATMENT OF REDUCIBLE HERNIA. THE treatment of a reducible rupture comprehends the return of the protruded parts, and their retention within the abdo- minal cavity by means of an appropriate truss. The necessary observations concern- ing the mode of replacing ruptures will be delivered when the treatment of strangu- lated hernia is considered. So long as the protruded viscera can be made to pass freely into the abdomen, this complaint carries with it no immediate danger to the patient. It may indeed be troublesome, both from the bulk of the swelling, and from the intestinal derange- ments, which the residence of the viscera in their unnatural situation is apt to create; but, independently of these circumstances, it may exist throughout life, without caus- D 34 TREATMENT OF ing more than slight inconvenience. This innocent state of the disorder cannot, how- ever, be at all depended on; as numerous accidental causes may at any time bring it into a condition, where the life of the pa- tient is exposed to the greatest risk. A trifling bodily exertion, by forcing down an additional quantity of the bowels, an excess in eating or drinking, an indiges- tion or any intestinal disorder may convert, the rupture from a reducible to an incarce- rated state. Should the patient escape this fate, the unrestrained increase of the swel- ling constitutes a sure source of future in- convenience and disease. The vast size, to which neglected herniæ sometimes increase, not only prohibits all active exertion; but, by involving, in the male, the integuments of the penis, incapacitates the subject from the act of copulation, and gives rise to ex- coriation from the discharge of the urine over the swelling. Disorders of the intes- tinal functions invariably attend these large ruptures, and increase in frequency and violence in proportion to the size of the swelling, and age of the patient. REDUCIBLE HERNIA. 35 These considerations should render every person, afflicted with a rupture, anxious to get the parts replaced, and to have a proper truss applied; and they should lead sur- geons to inculcate the necessity of these measures, as forcibly as they can, on the minds of all such as seek relief from their advice. As modern practitioners are universally agreed in the propriety of trusting to the use of trusses only, as a means of obviating the danger and inconvenience which a rup- ture may produce; and as the various me- thods proposed, I will not say employed, by the older surgeons, with the view of preventing the return of the complaint, would expose the patient's life to the most imminent risk, without affording any greater chance of an effectual cure than the use of trusses would bestow; we may allow the operations devised for the purpose of a ra- dical cure to descend quietly into oblivion, without wasting our time in the description or consideration of them. D 2 36 CONSTRUCTION AND oger Construction and Use of Trusses. Herniary bandages are of two kinds, the elastic and non-elastic: we can trust to the former only for accomplishing our ob- ject; they keep up an uniform pressure un- der every variation of circumstances, and are in all points of view so vastly superior to the latter, that these have fallen almost completely into disuse. The most important part of an elastic truss consists of a flat and narrow piece of steel, adapted to the form of the body, and called the spring. This passes round the affected side of the trunk, terminates ante- riorly in an expanded plate placed over the mouth of the sac, and extends behind to various distances beyond the spine. The posterior surface of the plate is furnished with a convex cushion termed the pad, and adapted in form and size to the opening, which it is designed to close. The spring is covered externally with leather, and that it may set easily on the body, its inner sur- USE OF TRUSSES. 37 face is lined with some soft substance; a strong strap extending from its posterior end passes round the sound side of the trunk, and is fastened to a hook on the front of the plate. A patient, who is ruptured on both sides of the body, must have a spring extending round the back and sides of the pelvis, and terminating anteriorly in two plates, each of which is furnished with a cushion for the hernia of its own side. A strap, sewed to one plate, and attached to a hook on the opposite side, serves to connect these to- gether. A double truss is sometimes made with two distinct springs, but it does not possess the stability of the former kind. The distance between the two openings must be carefully marked in taking the measure for a double truss, and accurately observed by the maker in executing his in- strument. When in inguinal or crural ruptures the pad rises higher than its proper situation, the truss receives the addition of a thigh- strap, which passes from the back of the spring under the affected thigh, and is at- 38 CONSTRUCTION AND tached to the plate by means of a hook. The inconvenience arising from the oppo- site defect, in which the pad sinks too low, must be remedied by a band going over the shoulders: we may sometimes accomplish our object, without making any addition to the truss, by merely changing the position of the hook to which the strap of the truss is fastened: when the pad rises too high, this hook should be placed towards the lower part of the plate, and vice versa. The measure for a truss is taken by pass- ing a string round the body, from the point at which the viscera are found to protrude, in that situation which it is intended that the instrument should occupy. In order to obtain a more exact representation of the form of the trunk, it is proposed to take the measure with a double flexible wire, which may be bent exactly to the form of the parts. In either case the alteration, made by covering the spring, requires that an inch should be allowed beyond the measure. In order that a ruptured person may de- rive all the benefit which a truss can afford, USE OF TRUSSES. 39 and avoid as much as possible the inconve- niences connected with its use; care should be taken, that the spring be constructed of a due strength; that the instrument set close to the body in every part, so as not to make any partial or irregular pressure; that it be not deranged by the necessary mo- tions of the body; and that the form of the pad be adapted to the part on which it lies. When the measure has been properly taken, much must depend on the execution of the artist; yet attention on the part of the surgeon may often detect the source of inconvenience. The strength of the pressure will be in proportion to the thickness and breadth of the spring. Small ruptures, and those, which occur in children, or in persons who do not lead a laborious life, and are not obliged to make great exertions, may be retained by a weaker truss than is required for cases of the opposite description. As the omentum escapes from the abdomen much more readily than the intestines, an epiplocele requires a proportionally stronger spring than an intestinal rupture. When 40 CONSTRUCTION AND the hernia is large and old, or the subject of it is exposed to the necessity of frequent laborious exertions, a strong truss is required. The patient should on no account wear a more powerful spring than his rupture re- quires, since the long-continued pressure of the pad must have the effect of weaken- ing and injuring the abdominal ring and surrounding parts. If the pad is too con- vex, the pressure is confined to one spot, at the side of which a protrusion may occur. When the case requires so strong a spring that the pressure on the spermatic chord.is painful, the pad may be constructed with a hollow to admit this part. A similar con- trivance may be found useful when rupture is combined with disease of the testis or spermatic chord. The form of the spring, and consequently the position which it occupies at the side of the pelvis, is a point of the greatest im- portance in obviating the possibility of a derangement from the motions of the trunk or hip. Sometimes it is carried horizontally round from the pad; and then it goes so near to the trochanter major as to be very USE OF TRUSSES. 41 easily displaced by the motions of the thigh. To avoid this defect, it has been brought midway between the crista of the ilium and the trochanter; but the same inconve- nience exists in a diminished degree: A truss has been constructed by Mr. Whitford, surgeon's instrument maker near St. Bartholomew's Hospital, different from any which I have hitherto seen in the form and course of the spring, and possessing ap- parently all the firmness and stability, which can be bestowed on these instruments.* The spring passes on the ruptured side just below the outer edge of the crista of the ilium, as far as the posterior superior spinous process of that bone. It then goes straight across to the same point of the opposite bone, and pursues its course, on the sound side of the pelvis, in the same relation to the crista ilii as it held on the side of the rupture, as far as the anterior superior spinous process, where it terminates as usual in a leathern strap. In this mode of construction the motions of the trunk and thigh cannot de- * The figures annexed to this work represent the spring separately, and the complete truss, as adapted to the body. 42 CONSTRUCTION AND range the instrument, which acquires a still further stability from the extension of the spring round the sound side of the pelvis. I have not seen enough of the actual em- ployment of this truss to speak very de- cidedly on the subject. I know that it has answered the expectations of the inventor in some cases, where the common trusses had been found inconvenient and insuffi- cient; and I think it therefore an act of jus- tice both to him and to the public to notice it on the present occasion, that it may be em- ployed in a greater number of instances, and that its merits may be appreciated according to the result of these trials. Trusses are sometimes fabricated with a pad moveable on a rack, so that its position can be changed according to the form of the abdo- men. In others the plate contains a screw, by which the cushion is pushed further in- ward, or allowed to recede at pleasure. A simple instrument, when well made, an- answers every end which can be accom- plished by these more complicated ones, and is therefore preferable to them for rea- sons which must be obvious. USE OF TRUSSES. 43 A compress of folded calico, placed under the pad, and renewed daily, preserves the truss from the effects of perspiration; and certainly in many instances increases the beneficial operation of the instrument, al- though we cannot explain the principles on which this effect is produced. The pad of the truss should be placed over the opening, at which the viscera have protruded: hence, in a small, or recently formed inguinal rupture, the proper posi- tion for it is considerably exterior to the pubis, and rather above that bone. The surgeon must, in all cases, endeavour to as- certain the precise point at which the rup- ture has taken place, and that is the right position for the pad. When he is going to apply the truss, he will place it round the pelvis, and put his patient into the recum- bent position. Having carefully replaced the whole protrusion, he presses on the opening with one hand, and with the other applies the pad of the truss in its proper situation, holding it there, until he has ad- justed the rest of the instrument, and fasten- ed the strap to the plate. The patient will 44 CONSTRUCTION AND follow the same plan in applying the instru- ment himself; and the most convenient time for this purpose is before he rises, as the viscera generally re-enter the abdomen during night, and have no disposition to descend again until he assumes the erect position. The use of an elastic truss, not only keeps the viscera within the abdominal cavity, and thereby protects the ruptured person from all the dangers, to which the existence of his complaint would otherwise expose him; but, if continued for a sufficient length of time, even affords a prospect of a radical cure. The constant pressure of the pad keeps the neck of the sac empty, and this part, together with the surrounding tendinous. opening contracts, in obedience to the gene- ral law, by which all hollow parts of the body adapt themselves to their contents. Sometimes the truss excites a kind of slow inflammation, which produces an actual ag- glutination of the sides of the aperture. In proportion, as the patient is younger, may we more reasonably expect a radical cure from the use of the truss. We may in- USE OF TRUSSES. 45 deed speak with confidence on this point in the ruptures of children. Although cures sometimes take place in adults, they cannot be regarded as matters of frequent occur- rence; and they are not at all to be ex- pected in old subjects. Some practitioners are inclined to pro- hibit the use of a steel truss in infants, but there is no foundation for this exception, and the instrument may be employed with perfect safety in the youngest persons. No benefit can be derived from the employment of a non-elastic bandage, which is some- times used in infants; and we may lay down a general rule, that the chance of a permanent cure is greater, the sooner we begin to employ the steel truss. The re- sistance in these cases is but weak, and a strong spring would therefore be not only injurious but useless. A small and recent hernia, which has been produced by some accidental exertion, affords the most favourable prospect of a radical cure from the application of a truss; which, on the contrary, offers nothing more than palliation in large and old ruptures, 46 CONSTRUCTION AND and those whose origin may be referred to predisposition. The truss must be worn without inter- mission by a person who hopes that its em- ployment may cause such a contraction of the ring and sac, as will prevent any future descent of the viscera. The same rule should indeed be observed by all, who are obliged to wear these instruments. It would be better indeed that no truss should ever be used, than for the patient, after wearing one for some time, to lay it aside suddenly: for a hernia reproduced under these circum- stances is much exposed to the occurrence of strangulation, and such an incarceration is particularly dangerous. If however the parts should not be strictured, their protru- sion dilates the sac and ring, which had be- gun to contract, and destroys the benefit already derived; the cure therefore com- mences again from this period. The incon- venience and restraint, occasioned by the first application of the instrument, induce us to allow the patient to sleep without it for a short time; enjoining him not to re- move it before he has lain down in bed, USE OF TRUSSES. 47 and to re-apply it before he, rises. This practice must be discontinued as soon as the patient's feelings will admit of it; and the constant wearing of the truss must then be strictly enforced. He should have at least two trusses, and will find it pleasant to change them in the morning. When the covering is much worn, or rendered irri- tating by the perspiration which it imbibes, it should be immediately renewed. When this plan of treatment has effected a radical cure, it may be laid aside; but prudent caution requires that the patient should be fully convinced of his cure before he discontinues the bandage; and he will do well to leave it off gradually, first at night and afterwards in the day time, avoid- ing all violent exertions which might cause a fresh protrusion. It must be allowed, after all, that trusses of the best construction, and most judicious application will not always prove a certain defence against a protrusion. Various acci- dental circumstances may derange the in- strument, and a portion of intestine, or more particularly of omentum may slip out 48 CONSTRUCTION AND USE OF TRUSSES. under the pad. For this reason bodily ex- ertion should be avoided as much as pos- sible; and the patient, when obliged to make any exertion, should press on the pad with his hand. If a protrusion should oc- cur, let him immediately take off the truss, lie down, and either return the part him- self, or send for his surgical attendant. TREATMENT OF IRREDUCIBLE HERNIA. 49 CHAP. III. TREATMENT OF IRREDUCIBLE HERNIA. THE reduction of a rupture may be im- practicable, although the protruded parts suffer no strangulation. Adhesion of the prolapsed viscera to each other, and to the sac, is sufficient to produce this effect; and it probably occurs in some instances, where reduction is not prevented by any obstacle of this kind, but only by the enlargement of the protruded parts. As the application of a truss in these cases is out of the ques- tion, the tumour must be supported by means of a suspensory bandage. Surgical observers* have recorded several cases, in which large, old, and irreducible ruptures, in consequence of long confine- ment to bed, have returned completely into *FAB. HILDANUS, cent. 5, obs. 54.-POTT's Works, vol. II. p. 73. E 50 TREATMENT OF the cavity of the abdomen. It has been proposed to imitate this operation of nature by the efforts of art, and the attempt has, in some instances, been attended with suc- cess. By confining the patient to bed, by restricting him to a light and sparing diet, and by the employment of venesection, ca- lomel, purgatives, and glysters, ARNAUD* accomplished the replacement of a vast scro- tal rupture, which had existed from infancy; and succeeded in numerous hernia which resisted every other method. His assertions on this subject are corroborated by the tes- timony of LE DRANT who witnessed the progress of many of his cases. The same plan has been successful in several instances in the practice of Mr. HEY.+ This treatment must induce a general state of weakness and relaxation, particularly favourable to the return of the protruded parts: it must also operate powerfully, by causing the absorption of accumulated fat, * ARNAUD on Hernias, p. 292. Also his Mémoires de Chirurgie, tom. II. + Traité des Operations, p. 114. + Practical Obs. p. 219. IRREDUCIBLE HERNIA. 51 in reducing the bulk of the hernial contents. For the latter reason we should expect it to be particularly successful in such ruptures as consist for the most part of omentum; and the recorded experience on this subject justifies our conclusion. In combination with the measures above described, con- siderable assistance may be derived from keeping up a constant pressure on the tu- mour by means of a suspensory bandage made to lace in front, and diminished in size according as the contents of the swel- ling recede.* When the reduction of the tumour has been effected, it must be kept up by the application of a truss. In some instances, where the parts have been re- turned, the ultimate success of the plan has been frustrated by an unexpected occur- rence. The parietes of the abdomen have become so far adapted to the diminished quantity of the viscera, that the sudden in- troduction of a large additional bulk could not be borne. A patient, who persisted * PETIT recommends for this purpose trusses with hollow pads; proposing to fill up the cavity, as the parts recede.- Traité des Malad. Chirurg. tom. II. p. 335, et seq. E 2 52 TREATMENT OF for a long time, under the direction of SCHMUCKER,* in keeping the parts reduced, was brought into a state of the greatest ex- tremity, which absolutely compelled him to remove the truss. This gentleman has seen many instances of the same kind: PETIT has even known the practice to prove fatal: the application of the truss after reduction caused nausea and vomiting, and other dis- tressing symptoms, which rendered its re- moval necessary, yet the hernia did not come down again, nor did the symptoms cease; and the patient died, as it appeared upon dissection, of inflammation of the pe- ritoneum.† In the case of an irreducible omental her- nia of moderate size, a truss with a hollow pad may be recommended, but an enterocele will not bear this treatment. Mr. COOPER has accomplished the reduc- tion of herniæ, in some instances, after the previous application of ice to the swelling. A person, who has a hernia incapable of * Chirurgische Wahrnehmungen, vol. II. p. 243. + Loco citato, p. 392. IRREDUCIBLE HERNIA. 53 reduction, is exposed to much greater dan- ger than the subject of a reducible rupture. Strangulation may take place at any time, in consequence of some straining or exer- tion; and complaints arising from affection of the intestinal canal make their appear- ance on the slightest exciting cause: hence it is particularly incumbent on patients of this description, to avoid all unusual efforts; and, by a strict attention to diet and the state of the fecal discharge, to keep the alimentary canal, as nearly as possible, in a healthy condition. Costiveness should be particularly guarded against. Irreducible herniæ must of course be ex- posed to all the consequences of external injury and violence; hence, various cases are recorded, in which the bowels have been burst by blows, falls, &c. 54 TREATMENT OF CHAP. IV. TREATMENT OF STRANGULATED HERNIA, THE indication of cure in incarcerated hernia, is to liberate the parts from stric- ture, and to replace them in their natural situation.* The treatment of the com- plaint, when examined in detail, will ap- pear more complicated than this view of the subject would lead us to expect; for,as * The propriety of establishing this, and this only, as the indication of cure for strangulated hernia, is so striking and obvious, that it would have been almost unnecessary to notice it here, had not RICHTER and CALLISEN, two of the most celebrated modern surgeons, represented the matter in a dif- ferent light. The objects of surgical treatment in this dis- order, according to these writers, are to obviate inflammation; to subdue spasm; to procure evacuations; and lastly, to re- place the rupture: thus they combat the effect while the cause continues to operate. The last is the only rational in- dication, and its accomplishment necessarily includes the at- tainment of the other objects.-See RICHTER Anfangsgründe der Wundarzneyhunst, vol. V. p. 238. CALLISEN Systema Chirurgia Hodierna, pars posterior, p. 464. STRANGULATED HERNIA. 55 persons of every age and constitution, and of all ranks and conditions of life, are sub- ject to the disorder, the means of accom- plishing the general indication must be modified by these circumstances: hence, we find that various methods of treatment have been proposed, which, though very different, and sometimes almost opposite to each other, may yet be all of them eligible in particular cases: their respective merits may in general be estimated by the degree in which they contribute to the accomplish- ment of the above-mentioned object. The principal means, which have been adopted for the cure of strangulated her- nia, are, bleeding; the warm bath; pur- gative medicines by the mouth, and in the form of glyster; injections of the decoction or smoke of tobacco; opiates and other an- tispasmodics; the cold bath, and various cold and warm applications to the part. The works of surgical writers afford nume- rous instances, in which all these methods have been successful; and the practice of most individuals would furnish similar re- sults. But the recital of single cases tends, 56 TREATMENT OF STRANGULATED HERNIA. as Mr. HEY has well observed, to advance our knowledge very little: our object should be to ascertain the comparative merits of each mode, and to deduce from thence ge- neral rules of practice. With this view I shall consider separately what is to be said on the subject of each of the above-men- tioned methods. SECT. I. The Taxis. WHEN a surgeon is called to a case of hernia, he attempts, in the first instance, to replace the protruded parts; which opera- tion is technically termed the taxis. When the swelling is free from stricture, this re- placement is generally very easy; but when the parts are more closely girt, the opera- tion is rendered proportionally difficult, and requires that attention should be paid to the position of the body, and to other circum- stances, which may influence the chance of success. The patient should lie down when THE TAXIS. 57 we attempt the taxis, as many circumstances prove that the recumbent position contri- butes materially to the, return of the pro- lapsed parts. When the rupture is of the inguinal or crural kind, the pelvis should be placed higher than the shoulders, so that the swelling itself may constitute the most elevated point of the trunk. The patient's bladder should be previously emptied; and he must carefully abstain from coughing, holding his breath, or any similar efforts. These precautions procure us as much room as possible in the abdominal cavity, and favour the return of the protruded parts, as far as that object can be effected, by the force of gravity. The position of the patient must also be regulated with a view to the opening, through which the parts have descended. Hence, in inguinal and crural hernia, the thigh should be bent, and rolled inwards; in order to relax the tendon of the external oblique muscle. It is also recommended to elevate the shoulders slightly, as well as the pelvis. This brings the trunk into a curved 58 TREATMENT OF STRANGULATED HERNIA. state, and completely relaxes the abdominal muscles. When things are thus prepared, the sur- geon begins his attempt by a gentle pressure on the tumour, which may be gradually in- creased, but should not be carried to such an extent as to cause pain:* violence can- not indeed be beneficial, as it is more likely to press the parts in a mass against the ring, than to urge them through the opening, We usually grasp the tumour with one hand, while the other is placed at the aper- ture, where it may be employed in facilita- ting the entrance of the parts, and in keeping up those which have been already returned. Success will often be obtained by exerting a general pressure on the whole surface of the swelling; in which method, both hands must be employed in order to subject the entire tumour to the action of the force. This method is strongly recommended by PETIT.† *The intestine has been burst by the employment of too great force in the attempts at reduction.-COOPER's Anatomy, &c. of Inguinal Hernia, p. 23. See also J. L. PETIT Traité des Maladies Chirurgicales, tom. II. p. 322. Loco citato, p. 323-328. THE TAXIS. $20 59 The pressure should be exerted accor- ding to the course in which the parts have been protruded: thus, the contents of a bubonocele pass obliquely downwards and inwards; those of a femoral rupture down- wards and then forwards; yet we should not confine ourselves entirely to such a kind of pressure as the course of the her- nia would suggest; but, in failure of those attempts, make other trials in different di- rections. The following manoeuvre will sometimes succeed in a bubonocele or scrotal hernia, af- ter the more ordinary methods have failed, particularly in cases, where the strangulation seems to have been caused by an accumu- lation of fecal matter. Let the surgeon embrace the neck of the swelling, close to the tendon, with the finger and thumb of one hand, and carry them downwards, with a moderate pressure, so as to remove the contents from the portion next to the ring; this will reduce the size of that part, which he may then attempt to pass into the ring with the other hand. The surgeon should place himself in a 60 TREATMENT OF STRANGULATED HERNIA. situation which he can occupy without in- convenience for a considerable time, since he must persist in his attempts for an hour in some cases, before he gives up the ex- pectation of success; and it often happens that, by perseverance in trying various po- sitions and modes of pressure, herniæ are ultimately replaced, which did not yield at all to the first attempts. If the efforts at reduction, managed ac- cording to the above directions, are not attended with success, the following me- thod has been recommended. A strong man placed in a convenient position near the edge of the bed, supports the lower extremities on his shoulders, so that the patient's head and chest only rest on the bed. Attempts at reduction in this pos- ture are said to have succeeded after every thing else had failed, and have therefore been highly recommended by some sur- geons. I cannot fairly appretiate the me- rits of this proposal, as I have never adopted the practice, nor seen it employed by others. It does not seem to me to promise any ad- vantages that could compensate for the un- THE TAXIS. 61 pleasantness, trouble, and inconvenience in- separably connected with its employment. The proposer of this manoeuvre must have expected to accomplish reduction by the mechanical effect which the weight and dragging of the viscera in the abdomen would have on the protruded parts. That this idea is completely absurd, must be im- mediately perceived by any one who forms a just notion of the natural state of parts; who is aware that the abdomen is accurate- ly full, and that all its contents are preserved in their relative positions by the pressure of the respiratory muscles; that they cannot therefore fall from one part of the cavity to another, but are probably just in the same place, whether the head or the heels be the most elevated point of the body. Reduction is opposed by the pressure which the pro- truded parts experience, and this position can neither overcome nor diminish that obstacle. The return of a piece of intestine is gene- rally preceded by a peculiar noise, caused by the passage of air through the strictured part. It recedes at first gradually, and then 62 TREATMENT OF STRANGULATED HERNIA. slips up suddenly. The omentum goes up slowly to the very last portion, which must be actually pushed through the opening. If the taxis should not succeed at first, it may often be successfully repeated after the use of the warm bath, bleeding, or cold ap- plications. The chance of returning a hernia will be proportionate to the size of the opening: hence small tumours are the most difficult of reduction, as they are always attended with the closest stricture; and this difficul- ty is experienced particularly in crural rup- tures, from the extreme narrowness of the aperture through which their contents de- scend. The probability of replacement is also materially influenced by the duration of the complaint; it is much less in the later than in the earlier stages of the stran- gulation, from the inflammatory disorder which arises in the prolapsed parts. When the rupture becomes painful, we are no longer justified in persevering in at- tempts at reduction by the hand. A suf- ficient pressure cannot now be endured; and the force, which is employed, only tends to THE TAXIS. 63 increase the inflammation, and accelerate the approach of gangrene. At this period the operation is required, and should be performed without delay. 565 The surgeon is not warranted in relying on the taxis as his chief method of accom- plishing reduction; he should not waste in unavailing efforts of this kind, that time which ought to be devoted to the prosecu- tion of more vigorous measures. When he cannot reduce a rupture at one fair trial, he has less and less chance of effecting this ob- ject in the subsequent progress of the case, unless he can produce an alteration in the state of the tumour by other means. My opinion on this subject is confirmed by the experience of RICHTER, whose words I shall take the liberty of quoting. "Je n'ai vu que très rarement une her- "nie vraiment incarcérée etre réduite par le 66 66 taxis, et lorsqu'on a pû la réduire, les cir- "constances avoient été tellement ameliorées par d'autres moyens, et les parties rentré- "rent si facilement et si inopinément, quoi- qu'on eut fait auparavant les tentatives en 66 66 vain, que j'ai penché toujours a croire qu 64 61 TREATMENT OF STRANGULATED HERNIA. 1 "elles seroient rentrées d'elles mêmes quel- ques heures plus tard."* 66 Mr. HEY+ also advises us to be cautious of doing too much, as he has seen great harm arise from long continued efforts to replace the strangulated intestine. The opinion of RICHTER and of Mr. HEY receives the strongest confirmation from the experience and reasoning of DESSAULT.‡ Long practice had shewn that justly famous surgeon, that ruptures, in which the inflam- matory symptoms are strongly marked, are seldom returned by the taxis, and that the repeated and forcible attempts at reduction§ employed before the operation, have a most *Traité des Hernies, trad. par ROUGEMONT, p. 66. + Practical Obs. p. 144. + Euvres Chirurgicales de DESAULT, tom. II. p. 332, 338. § Those, who, have seen much hospital practice, will re- cognise the justice of the following remark. "Il en est des "hernies etranglées comme de l'introduction des sondes dans les rétrécissemens de l'urétre; il faut, avant de re- "courir aux derniers moyens, que chacun se soit épuisé en "secours préliminaires; il faut que l'effort de tous les con- "sultans passe, pour ainsi dire, sur la tumeur; s'ils sont "nombreux, est-il possible qu'elle ne soit pas meurtrie, de- "chirée surtout si, comme il arrive, chacun cherche a l'envi " à obtenir, a force de pressions ce à quoi n'a pu réussir ce- "lui qui l'a précédé ?"-p. 336. THE TAXIS. 65 decidedly unfavourable influence on the event of the case; hence he was led to pro- scribe the taxis in the inflammatory stran- gulation, until the previous use of other means had produced a change in the state of the swelling; and he justifies his conduct by the comparison of two lists of patients operated on at the Hôtel Dieu: in one of these were contained the names of patients, on whom reduction by the hand had been attempted before the operation in the usual manner; and in the other, of those, who had been operated on without such at- tempts. The reader will not, I hope, conceive, that the remarks, which I have now made, are intended to convey a general disappro- bation of the use of the taxis. They are applied to those cases only, in which the existence of considerable pain in the swel- ling and abdomen, together with other cir- cumstances, denotes that the incarceration is of the inflammatory kind. Where the rupture is tolerably free from pain and ten- sion, and the general character of the case F 66 TREATMENT OF STRANGULATED HERNIA. is slow and languid, a judicious use of the taxis can never be injurious. The reduction of the rupture does not al- ways terminate the complaint: the symp- toms do not cease until the patient has had fecal evacuations, which, from the weaken- ed and disordered state of the alimentary canal, seldom take place spontaneously. Mild purgatives and glysters are necessary to free the intestines from that load of fecal contents which irritates and oppresses them. These remedies must be occasionally re- peated until the intestines have regained their healthy state: they are particularly necessary where the strangulation seems to proceed from an accumulation of matters in the canal. The patient is also exposed to the risk of a much more dangerous occurrence; viz. inflammation of the bowels. This will be indicated by the well-known symptoms, and must be treated accordingly. BLOOD LETTING: 67 SECT. II. Blood letting. THE use of blood letting in strangulated hernia has been very freely adopted, and warmly recommended by the most cele- brated modern surgeons. The grounds of this practice are derived from the state of inflammation which occurs sooner or later in the prolapsed parts, and which is propa- gated from that source over the whole ab- domen. Besides its effects in curing and preventing inflammation, the state of faint- ness, which it produces, is said to be pecu- liarly favourable to reduction. Mr. Port*, 66 Perhaps there is no disease affecting the human body, "in which bleeding is found more immediately and emi- nently serviceable than in this; and which, therefore, if "there are no particular circumstances in the constitution "prohibiting it, ought never to be omitted; but, on the "contrary, should be freely and largely repeated, if it appears 66 at all necessary."-POTT's Works, vol. II. p. 79. SHARP'S advice on this subject is just the same.-Treatise on the Ope- rations, edit. x. p. 17. F 2 68 TREATMENT OF STRANGULATED HERNIA. in this country, has been the most strenuous advocate of venesection, and the high es- teem in which his writings are most deser- vedly held has, no doubt, been a chief cause of its very general employment. RICHTER* and CALLISEN,† the authors of the most approved continental systems of surgery, have been no less forward in re- commending the free and almost indiscri- minate use of the lancet in this complaint. Yet the authority of these great names has not gained universal assent to their opinions. Some eminent surgeons of this country have not only doubted the utility of venesection in strangulated hernia, but have published opinions most decidedly adverse to the prac- tice. Mr. WILMER of Coventry, and Mr. * "Aussitôt que la hernie est douleureuse, il faut saigner, "de quelque espéce que soit l'étranglement." 66 RICHTER, Traité des Hernies, p. 93. t Præcipuus vero cardo vertitur in sanguinis detrac-