Ꮴ
ARTES
LIBRARY VERITAS
SCIENTIA
OF THE
UNIVERSITY OF MICHIGAN
WITH
TCEBOR
QUERIS PENINSULAM-AMGENAM
CIRCUMSPICE
The
George E. Wantz
(UM Medicine 1946)
Collection



ON THE
OPERATIONS
FOR
STRANGULATED HERNIA.


For
Zr Bridge
From the Author
PRACTICAL OBSERVATIONS
ON THE
OPERATIONS
FOR
STRANGULATED HERNIA.
BY
F.R.C.S.
J. H. JAMES, F.R.C.S.,
CONSULTING SURGEON TO, AND LATE SENIOR SURGEON OF, THE DEVON AND EXETER HOSPITAL;
CONSULTING SURGEON TO THE EXETER DISPENSARY,
MEDICINA
LITERIS
199
LONDON:
JOHN CHURCHILL, (NEW BURLINGTON STREET.)
MDCCCLIX.
1859

AUGMAN
RARE BOOK ROOM
RD
621-
-135
LONDON
PRINTED BY J. E. ADLARD,
BARTHOLOMEW CLOSE.

PRELIMINARY REMARKS.
remarks.
IT has been my fortune to have been the surgeon of
a large provincial hospital for a long period. From the
commencement of my charge it has been my custom to
record the most interesting cases which have occurred,
and of course the operations, more especially those per-
formed by myself. The result is a great
accumulation of facts, and perhaps of some Preliminary
useful observations; if so, no apology would
be necessary for offering such results to the public.
Under a similar conviction I have already submitted a
considerable number of cases, and remarks, On the
Causes of Mortality after Amputation,' which appear to
have obtained favorable notice. Another, hardly less
important series, is that of Hernia. So much has
been written on this subject, that it might be supposed
to be exhausted. The number and weight of names to
be found in the history of hernia perhaps exceed those
in any other branch of surgery, yet there never was a
1

RD
521
135
LONDON
PRINTED BY J. E. ADLARD,
BARTHOLOMEW CLOSE.

PRELIMINARY REMARKS.
It has been my fortune to have been the surgeon of
a large provincial hospital for a long period. From the
commencement of my charge it has been my custom to
record the most interesting cases which have occurred,
and of course the operations, more especially those per-
formed by myself. The result is a great
Preliminary
accumulation of facts, and perhaps of some remarks.
useful observations; if so, no apology would
be necessary for offering such results to the public.
Under a similar conviction I have already submitted a
considerable number of cases, and remarks, On the
Causes of Mortality after Amputation,' which appear to
have obtained favorable notice. Another, hardly less
important series, is that of Hernia. So much has
been written on this subject, that it might be supposed
to be exhausted. The number and weight of names to
be found in the history of hernia perhaps exceed those
in any other branch of surgery, yet there never was a
1

2
PRELIMINARY REMARKS.
time when more numerous or more important contri-
butions to its pathology have been offered, than in quite
recent years.
New facts; new proposals. The pro-
fession was never more keenly alive to its importance.
A memoir on hernia, even at this late hour, if sufficiently
practical, may not be out of place.
The opportunities I have enjoyed, considerable as they
have been, are not to be compared with those which the
great metropolitan hospitals afford; but when I see that
one of the most valuable contributions on this subject
was from the pen of a surgeon whose experience, at the
time he wrote, was not much greater than my own,*
I should not be deterred from the attempt simply from
this consideration. Whether the remarks I have to
offer, founded on what I have myself seen and done,
and on facts collated from other sources, sufficiently
warrant the publication, must be left to the judgment
of others. The character of this memoir must not be
misunderstood. It does not pretend to be a treatise on
hernia; such an attempt would be much out of place
when there are so many and so good; the object is,
as briefly as possible, to give the result of my own
experience, either as confirmatory of some, or as opposed
to other, points of practice, which may now be more or
less in esteem, giving reasons for my opinions when
they differ from those of others, and offering, in some
instances, views which I believe to be new, though it is
indeed difficult to say what is really so.
As these observations are founded on my own practical
* "I have now, at the time of writing this, performed the operation forty
times." (Hey, p. 130, 2d edit.; thirty-five, when he first published.)
MIU

PRELIMINARY REMARKS.
3
opportunities, it is right they should be particularly
stated. They have been partly derived from my own
cases, partly from assisting others either in public or in
private. I have, altogether, tolerably copious notes of
about one hundred operations; these, however, consti-
tute only a portion of those at which I have assisted,
but of which I have either no records, or they are very
brief. For obvious reasons I confine myself to the
narration of my own; these amount to thirty-six, besides
one very remarkable case of supposed umbilical hernia,
which will be subjoined.
I have given all these cases, as I entirely assent to
Mr. Luke's opinion, "that cases collected in publications
from the separate experience of many surgeons seem
wholly insufficient, and are almost worthless unless they
embrace the entire of such experience;"* and I have
omitted no material fact, however unsatisfactory to
myself it may be. If any case were suppressed, or any
important circumstance withheld, the value of the whole
would be greatly impaired, and the force of any obser-
vations materially weakened. To deal fairly with the
public, the "adversaria omnia" should be fully given.
The great fault of our principal works on operative
surgery is, that they give just information as to standard
methods and ordinary contingences, but, with not very
many exceptions, do not sufficiently point out the diffi-
culties, and the means of avoiding them; like charts
which give the course of navigation, but not the rocks,
the shoals, and the quicksands. I do not apply this to
*Med.-Chir. Trans.,' vol. xxxi, p. 97.

4
PRELIMINARY REMARKS.
hernia in particular; perhaps it less deserves the remark
than many other operations.
Cases may be taken, and cases may be given in
various forms. I should say that, in noting them, a free
but faithful record is better than a cramped register,
which imposes fetters inimical to freedom of thought;
but as regards giving them, a different course may often
be pursued with advantage. Cases may be selected for
a particular purpose. It is often right to do so. These
should be related in continuation, and in such a manner
as to convey the especial information required, without
encumbering the narrative with unnecessary detail; and
of such we have many admirable examples. If, however,
we propose to give the whole information we possess
regarding a particular disease, the tabulated form is, I
conceive, the best: at all events it tests the accuracy of
the record. It appeared to me, that if my notes were
not sufficient to supply the information which such
tables require, I might well doubt the propriety of
founding any argument upon them, and I therefore
submitted them to the test of such arrangement as will
be found in Mr. South's very able commentary on
Chelius.* As these cases of mine were taken with no
view of publishing them, still less with any arrangement
in the nature of a register, it cannot be expected that
they should fulfil in every instance the conditions which
such a register demands. Yet, with one exception,
they meet the object better than might have been
*Vol. ii, p. 50. Another important table, by Mr. Gay, has come to my
hands since this was written, containing twenty-two cases. ('Medical Times
and Gazette,' Aug. 14, 1858.)

PRELIMINARY REMARKS.
5
expected that exception regards the wearing a truss-
an omission I regret, for more importance really attaches
to it than at first sight might be supposed. I have,
however, omitted to record it in so many instances, that
I thought it better to construct my tables (in other
respects the same as Mr. South's) without this column.
The tabulated form does not exclude the full develop-
ment of a case. Under the head Remarks, will be found
a brief statement of those additional circumstances which
the course of the symptoms, or the examination, if death
took place, may have supplied.
I have arranged these cases in three tables: the first
giving all the recoveries; the second, the fatal cases in
private practice; the third, those which occurred in the
hospital. The convenience of giving the recoveries and
deaths apart from each other is obvious, with reference
to any inquiry; the object of separating the fatal cases
in private and in hospital, will be stated in its place.
The practice pursued at this hospital, with little
exception hitherto, has been to open the sac; conse-
quently, from my own experience, I could venture no
opinion on the comparative merits of the two operations.
Nevertheless, there is no point which so much demands
inquiry. The question naturally presents itself to every
mind, why a method recommended by so great a surgeon
as Petit, and supported by the opinion and practice of
other eminent surgeons of his day, should have fallen
into disuse, unless there were some cogent reason for it,
founded on its ill success. We have seen it revived,
with some modifications, by men of undoubted skill.
We find that the results appear to have been attended

6
PRELIMINARY REMARKS.
with great success, but still it becomes a most important
matter to inquire whether the principles on which it is
supported are altogether so just as at present supposed;
whether the analogy with the taxis is true; and whether
the comparative success of the two methods, if fairly esti-
mated, is so different as has been represented.
If, as stated, I have little experience of the operation
without opening the sac, it may naturally be demanded,
on what facts I ground my arguments; now it so
happens, that I can refer to a most valuable series of
statements, which give indifferently the results as con-
nected with either method, which appear to have been
collected without bias; and to give the issue, with
sufficient circumstances to warrant conclusions. They
embrace the practice of the principal metropolitan
hospitals for three years, and of the most eminent advo-
cates of both methods, as well as of those who are free
from any partiality. I allude to the statistics lately
published in the Medical Times and Gazette.'*
6
With respect to these, I have in the first place sepa-
rated the cases operated on in the usual method, and
have analysed those which proved fatal; and when they
appear to have been unavoidably so, have given the
reasons for supposing them so, thus exonerating the
mode of operating in those numerous instances in which
such reasons can be fairly urged. In the second place,
* Those of several provincial hospitals have since been published, which,
as far as I can judge, do not oppose the former; but I doubt much,
whether Petit's operation has, as yet, been extensively adopted in the
provinces; at all events the former series is quite large enough to answer
my purpose.

STATEMENT OF EXPERIENCE.
7
I have given the deaths which occurred after Petit's
operation, and the reasons for supposing that the most
strenuous advocates of it have scarcely taken a complete
and unbiassed view of the principles on which the
success of either method may depend-a bold under-
taking, doubtless, when such and so great are the advo-
cates for that method; but as it is an undoubted duty of
the profession to settle, if possible, not so much which is
the best method in all cases, but which is the preferable
one in particular cases, I believe that any endeavour,
however imperfect, to advance this knowledge, will meet
with a favorable acceptance.
To proceed:
Of the 36 cases operated on by me, 22
Statement of
were femoral, 14 inguinal and scrotal; 24 my own cases.
were in hospital, 12 in private practice-of the latter
6 died, of the former 8. The proportion in private
practice appears large, but, as regards these, extrinsic
causes powerfully influenced the results, as will appear
hereafter; and as to the total mortality, a comparison
with the statistics given from authentic sources will
show that it is far from being excessive. Mr. Erichsen
says, that of 545 cases recorded in the Proportion of
journals, 260 are reported to have died.* deaths.
Of 266 cases recorded consecutively in the Medical
Times and Gazette,' hereafter more particularly stated,
where the sac was opened, 125 died. These were
hospital cases, and if the proportion of my own hospital
* Erichsen, p. 757. Of Mr. Gay's cases, eleven died out of twenty-two;
and so of many others.

AGE-ITS INFLUENCE ON RESULTS.
cases is considered, i. e. 24: 8, the results are more
favorable. It will be seen that on the whole the opera-
tion for strangulated hernia is attended with a greater
amount of mortality than lithotomy, amputation (ex-
cepting primary of the thigh), or indeed almost any
other which falls to our lot to perform.
Of the average age I cannot speak positively. My
notes from which the age is taken include the cases of
other surgeons as well as my own, and a surgeon's note-
book is not intended to be an exact register. I may,
however, say, that in 30 cases of femoral
Average age. hernia, where the age is stated, it gives
rather more than fifty-seven years as the average, and in
a large proportion of others, where the figures are not
given, the patients are entered as "old." In inguinal
and scrotal it was much less: 16 cases are stated, giving
an average of forty-seven years, but this includes a lad
of eighteen and a boy of eight.
*
This statement of age
accords with those of much more extensive sources.
This question of age as regards the operation for
strangulated hernia is by no means a matter of merely
curious speculation. In the first place, the much greater
frequency may be attributed to the fact, that the liability
to hernia increases in a very great proportion as people
grow older. Thus (quoting Malgaigne, on the authority
of Mr. Erichsen, p. 735) while at twenty-one the propor-
tion of persons having hernia is 1 in 32, at seventy-six it is
1 in 3. If so, we need not wonder at the number of cases
* Mr. Bryant, in a very interesting memoir, published in the 'Reports
of Guy's Hospital,' 1856, gives the average age in femoral hernia at fifty-
five; inguinal, forty-three.

INGUINAL HERNIA IN FEMALES-DIAGNOSIS. 9
opinion that
The prevalent
hernia in old
strangulated
people is com-
monly of a chro-
nic nature very
doubtful.
of strangulation in advanced life; not greater, probably, in
proportion to the total number of persons so afflicted than
at an earlier age. In the second place, it would
lead us to doubt the validity of the opinion
so generally entertained, of cases of strangu-
lation in old people bearing a chronic
character. If, as appears, strangulation
occurs in so large a proportion of instances
in advanced life, and if, also, the larger number of cases
which occur altogether are of an acute character, as I
believe they are, we must not be misled by the suppo-
sition that age affords presumptive proof of its being
otherwise than acute. As far as my own experience
goes, a reference shows that in the majority of cases in
advanced age the character was severe and rapid.
Inguinal hernia
in the female
very rare.
There can
There was no case of inguinal hernia in a female
operated on. A circumstance which shows
that it must be comparatively rare; and I
know of only one of strangulation, which
was returned in this hospital by the taxis.
be no doubt of its occasional occurrence; and it is very
remarkable that this form of hernia without strangulation
is by no means infrequent, for it appears from the table
given by Mr. Lawrence, p. 11, that out of 15,786
females receiving trusses from the London Society,
1383 had inguinal hernia.
I may in this place make some remarks
on the diagnosis of this form of hernia in
the female. It is commonly grounded on
the fact, that Poupart's ligament is situated
Diagnosis of in-
guinal hernia in
the female as at
present accept-
edincases where
very large, not
satisfactory.

10
TIME-ITS IMPORTANT INFLUENCE.
below.
above it, and this is a sure distinctive mark when it
can be made out, but it frequently happens that
it cannot; that the tumour is so large, and so little
moveable, that the course of the ligament cannot be
traced. I refer to two cases, i. e. No. 4 in my Table
of Recoveries, and No. 6, Fatal in Private, occurring to
myself. I have seen it in the practice of others; and I
further refer to three cases narrated by Mr. South,*
with no reference, however, to the diagnosis. I would
then submit the following considerations. If the hernia
be true inguinal, it must of course come through the
inner ring, and take the usual course into the groin and
labium; but in such cases as these the cause
of obscurity is that the tumour mounts nearly
to the spine of the ilium, a fact which of
itself, I think, declares its nature. I am
not aware that this has been pointed out as a ground of
diagnosis; to me it seems conclusive, for in no other
case does it ascend high, except in the congenital hernia
of males, and then not to the same extent.
An additional
source of diag-
nosis submit-
ted.
Time the most
important ele-
ment in the re-
sults of hernia.
Probably the most important element in
the consideration of treatment, is Time.
How it operates so adversely, an attempt
will be made to show more particularly hereafter. As a
general principle, the danger seems to be in an inverse
* Vol. ii, pp. 75-77. Mr. Luke also, while describing the extent to
which femoral hernia often overlaps the ligament, says, "When the tumour
thus rises over Poupart's ligament, there are not any certain means of
ascertaining the precise seat of the stricture until the ligament itself is ex-
posed by the operation." (p. 111.) So also Mr. Gay, Medical Times and
Gazette,' August, 1858.

DISTINCTIONS INTO ACUTE AND CHRONIC.
11
ratio as respects its lapse. All authorities are now
agreed upon this, and the best have long been so, but
the measure must not be taken too broadly. It is
strictly true in its general application, but it greatly
differs in different cases. It is not safe to measure it
by days or hours; as great an advance in danger shall
occur in one case in twenty-four hours, or Qualified in dif-
less, as in another in three or four days; ferent cases.
indeed there are many cases of death on record, within
twenty-four hours; and I may add, what is highly im.
portant, that the degree of pain or tenderness of the
abdomen, or other symptoms, often afford no true cri-
terion for judging as my own cases, and many others,
will show, though doubtless the contrary is more gene-
rally true. The distinctions, moreover, which have been
made of acute and chronic, incarcerated and
The distinc-
tions usually
made as to the
character of
herniæ,as acute
or chronic, in-
carcerated or
strangulated,
doubtful, and
perhaps decep-
tive.
strangulated, &c., appear to me to be only
partially just, and therefore rather calcu-
lated to mislead than to assist. They are,
I submit, only questions of degree, and the
degree is apt to change with unexpected ra-
pidity. Certain points, however, may be ad-
mitted as affording probabilities, i. e. that an
old hernia will be less rapid in its progress than a recent
one; a large than a small; an inguinal than a femoral;
an omental than an intestinal-but as regards omental,
it should be well considered that although before an
operation we may sufficiently ascertain the presence of
omentum, we can never positively ascertain the absence
of intestine. A merely omental hernia would justify
delay, if the point could be determined; and if free

12
CASES JUSTIFYING DELAY.S
Omento-intes-
tinal probably
the most dan-
gerous.
passage of the bowels exists in a hernia of omental
character, it may, perhaps, be assumed that it is so.
Although omental hernia are less dangerous than in-
testinal, I may be permitted to express my doubts
whether the case is not very much other-
wise as regards omento-intestinal; but I
shall reserve my observations on this point
until my cases are stated.
To return to the question of time. There can be no
doubt that, as a general principle, when measures which
are known to be worthy of trial have fairly received it,
nothing but constantly and rapidly increasing danger
No delay al- can be expected from delay in the majority
lowable after of cases; still many occur when either from
trials of proba- their being purely omental, or, if intestinal,
the exception of no extreme character, or, it may be, a
simply inflamed hernia, or where the symp-
character. toms may be suspected to arise from causes
occurring in other parts of the abdomen, and which,
although coexisting with the hernia, may not have pro-
ceeded from it (as well shown by Mr. Pott)-doubts may
well be entertained as to the propriety or time of
operating. These are cases requiring the greatest judg-
ment, and the most careful watching. An unnecessary
operation may be performed, and prove fatal; or a
necessary one be unduly postponed, and the opportunity
for relief lost.
due recourse to
ble avail, with
of certain cases
of doubtful
On the methods of relieving strangulated hernia I
shall now offer such remarks as have occurred to me;
The taxis. and first as regards the taxis. All reports

TAXIS-ITS RESULTS CONSIDERED.
13
66
If accomplished
almost invaria-
bly saves life.
confirm the fact, that the chances of death,
when it succeeds, are exceedingly small.
(This will bear on an argument to be stated
hereafter.) Mr. Luke records 206 cases relieved in the
London Hospital without a death.* I have myself never
known a death to occur when the taxis has succeeded,
nor can I find a case to have occurred to any of my
colleagues. It is, however, fair to state, that Mr. King
has given 4 deaths in 40; Mr. Textor 9 in 114; † but
all other evidence is quite contrary. Dessault's axiom is
well known: Think favorably of a hernia which has
not been handled before an operation." This, I submit,
may be modified. It is not because it has been handled,
so much as because its not answering to the handling
shows that it has made too great progress to be otherwise
than dangerous. Again, I may say, that however urgent
the symptoms may have been, if the taxis has succeeded
they have almost invariably subsided, and soon ceased.
A person may have had pain in the abdomen, especially
at the stomach, vomiting, hiccough, and great pain at
the stricture. The contents are returned;
instant relief is proclaimed; the symptoms
cease, and the bowels are promptly moved.
To this fact I shall again refer, but it is
necessary to bear its extreme importance in mind, inas-
much as it has been the tendency of late to caution too
strongly against attempts to relieve by this method, or
speedily ceas-
The symptoms
ing, however
severe.
*Page 101. Mr. Ward's testimony, derived from the experience of the
same hospital, is strongly to the same effect. (Lancet,' Jan. 19, 1856.)
† Luke, p. 101.
Mr. Macilwain, whose treatise I received since this memoir was pre-

14
TAXIS-ITS RESULTS CONSIDERED.
A comparison
with the results
of either of the
decisive opera-
tions by inci-
sion, justifies a
fair and full
trial.
at least to limit them. There can be no question that
in every case where the taxis has been attempted, and
does not succeed, the contents are more or less damaged
by it; but when the full amount of benefit
it confers, if successful, is duly appreciated,
and when the mortality under either opera-
tion is contrasted with this, a considerable
degree of risk may be fairly incurred to
obtain so great an immunity. Any force
must be employed with great discretion when the hernia
has been of long continuance, or is very tender; but in a
recent case, where not so, the attempt should not be
hastily abandoned, for by so doing, unless one of the
operations be immediately performed, the chances are
that the hernia may run into an irremediable condition.
(Cases do occur, no doubt, where the bowel has given
way under the attempt, but they are not common: I
never met with an instance.) The interval
which is often allowed to elapse between
the abandonment of the taxis and either
The adverse re-
sults which are
imputed to the
taxis are more
justly attribu-
table to the de- operation, for the sake of trying other
lay occasioned methods, is often more fatal than the taxis.
by vain at-
Mr. Key* advances an objection to the
taxis which I think may be met. He states
tempts by other
means.
An objection to
the taxis al-
leged by Mr.
Key hardly
sustainable.
that the contents of a hernial sac, having
been bruised by the force used, are in the
same condition as other bruised parts, if a
pared for the press, has given some very useful observations on the criteria,
which may enable us to judge of the probability of the success of the taxis
under different conditions of strangulated hernia.
* Pages 58 and 59.

MEANS AUXILIARY TO THE TAXIS.
15
wound be superadded, and he employs this as an
especial argument for not opening the sac, and exposing
them to the contact of air; but the analogy, I submit, is
imperfect. In ordinary contused wounds the parts
beneath remain subject to the influence of the wound,
with which they are continuous, but after the operation
for hernia the contents, bruised if they have been, are
commonly removed into the abdomen; at the same time
it must be allowed, that if the external parts take on an
unfavorable condition, and lymph has not barred the
communication with the abdomen, to a certain extent,
the influence of this condition may be extended to
them.
In aid of the taxis there are various auxiliary means:
a few remarks on these may not be out of Means auxili-
place. Warm bath.-As far as my own ary to the taxis.
experience goes, I should say this has been the most
generally successful agent, and, if it fails, the least in-
jurious. To give it every chance it should be long con-
tinued, and the bath itself calculated to afford perfect
facility for placing the patient in the most favorable
position, so as to give the manipulations of the surgeon
every chance, and he, too, should be placed favorably,
to maintain a careful and continued pressure.
Chloroform.-It may be presumed that if warm bath,
chloroform, or tobacco serve, it is mainly by relaxing
the stricture, and the resistance of the abdominal
muscles; if the former, it must render doubtful the
opinions of those who do not allow any contractile power
to the stricture; but of this more in the sequel. I have

16
MEANS AUXILIARY TO THE TAXIS.
seldom seen it succeed, and it is at all events a matter
One objection deserving consideration, that as it super-
to chloroform. sedes the expression of pain, we cannot
calculate the degree of injury our manipulations may
produce.
Peculiar pow-
Tobacco.-Chloroform seems to have been much ac-
cepted in lieu of tobacco; but I conceive
it is a great mistake to consider their
modus operandi analogous.
ers of tobac-
co, perhaps not
sufficiently es-
timated.
Both will occa-
sion muscular relaxation; but chloroform
does not unload the capillaries; still more, it does not
seem to produce the remarkable influence on the peri-
staltic motion of the lower bowels which tobacco injections
occasion. It is by so doing, as I believe (the muscular
resistance of the viè animale being at the same time
suspended), that the imprisoned portion of the bowel is
often extricated.* Tobacco, however, is not always safe;
still more, it involves delay, for if unsuccessful, it is not
wise to operate in the subsequent collapse; furthermore,
it is a consideration, whether peritonitis be existing, or
supervene, and if so, being of low type, this may not
be enhanced by this agent. I have often seen it suc-
ceed, however, and it has the sanction of great autho-
rities.
The Long Tube, recommended, and justly, by Dr.
O'Beirne. I have seen three cases relieved by it. With
respect to its modus operandi, I am inclined to think
that it is partly on the principle just stated, namely, that
* I believe there can be little doubt of this effect being produced by
tobacco. I am not aware that this double effect has been noticed as re-
gards hernia, but it may have been.

MEANS AUXILIARY TO THE TAXIS.
17
it mechanically excites the peristaltic action downwards
of a long portion of bowel, but by allowing injections to
be thrown high up, it further serves, on the same prin-
ciple. It has not liberated any amount of imprisoned
flatus, in the cases I have seen, and as the tract of
bowel below the hernia is generally contracted, it may be
doubted whether, flatus not being present there, it
affords much benefit in this way.
Traction from within.-The object of the taxis is to
press back the contents, by a force acting from without;
the last two agents are calculated to withdraw them, by
a force acting from within; a more purely mechanical
but really not less scientific plan, is one, now rarely
adopted, excepting by the common people, who, how-
ever, do it very awkwardly; namely, employing the trac-
tion produced by the weight of the bowels themselves.
A method recommended by Pott, and other great
surgeons, is not to be lightly thought of, and if due care
be taken to relax the resistance of the abdominal muscles,
while the pelvis is raised to a vertical position, it is
worth a trial. I have used it, but rarely, and then with-
out success, but I have known better fortune to have
attended the attempts of others.
Obstinate con-
traction of the
abdominalmus-
A very serious obstacle to the return of the contents,
and one not sufficiently estimated, is the
muscular resistance of the abdominal pari-
etes, especially when, as often happens,
the bowels are inflated. A mode of elud-
ing this has been lately proposed by Dr.
Buchanan,* and is well deserving of trial.
cles and ten-
tus constantly
sion from fla-
afford serious
obstacles to re-
duction.
* Glasgow Med. Journ.,' July, 1856. The effects of this resistance are
also dwelt on by Mr. Macilwain.
2

18
MEANS AUXILIARY TO THE TAXIS.
Topical Remedies.-In those doubtful cases, where
there is reason to suppose we have to deal with an in-
flamed, rather than a strangulated hernia; also in cases,
of no urgent character, or in those which are in all
probability, purely omental, leeches, fomentations, and
poultices, are often of essential service; but in cases of a
decided character it is a loss of time to employ them, as
far as I can judge.
Of extreme cold, produced by ice or otherwise, it be-
comes me to speak with great hesitation, considering the
high authorities which commend its use.
I have rarely
tried it myself, but I have seen it often employed by
others, and with little or no success, as far as I can
recollect. It is a plan calculated to do harm, if it does
nor succeed, for the bowels are little intended by nature
for such treatment; and, indeed, as regards the principle
on which it acts, unless very carefully applied, it may
counteract its own agency, since, if the stricture is
capable of contraction, that may be influenced as much
as the contents. While upon this subject, I may refer
to a case, which remarkably showed the sympathy be-
tween the descended bowel and the general system,
namely, a large scrotal hernia, No. 3, Tab. 1,
when the patient was in such a state of
Great sym-
pathy between utter collapse, that I durst not operate, and
the contents of when no internal stimuli rallied him I
the general sys- had the part stuped with hot spirituous
fomentations, and it succeeded in esta-
blishing a general reaction, when I operated with success.
the hernia and
tem.
Of General Remedies little need be said. All surgeons
are agreed, that opium is often useful, especially when
delay is an object for any reason, especially as Mr. Hey

OPERATION BY OPENING THE SAC.
19
has advised, when patients are to be removed to long
distances for the sake of operation. Purgatives, gene-
rally speaking, to be avoided, excepting as enemata,
which are often useful, especially in the doubtful cases
before alluded to. General bleeding of late years has
much fallen into disuse, perhaps more than it ought;
I employed it with advantage in my earlier practice, and
I think a fair statement would be this: that to reduce a
strangulated hernia, faintness being often the most effi-
cient agent, if bleeding is carried to this extent, it may
serve, like tobacco and warm bath; but beyond this, its
effects must be taken both for good and ill: for good,
when there is an existing peritonitis of sthenic cha-
racter; for ill, when it is the reverse; in every case,
therefore, the plan adopted must be based on the merits
of that case.
I must next proceed to speak of the operation itself.
sac.
In my own practice I have, with one ex- Operation by
ception, adopted the old method of opening opening the
the sac, and to that my observations will
chiefly apply; hereafter, I shall venture to examine the
respective merits of the two, resting upon data which
have been before alluded to; but this I may at once
say, that in a large proportion of inguinal hernia, and
in a considerable proportion of femoral, there is strong
reason to suppose that the method by opening the sac,
will continue to be practised, and therefore if it be in
my power to give useful information upon this point, the
attempt may not be without its value. The remarks I
have to make, will be chiefly, on the difficulties to be

20
OPERATION BY OPENING THE SAC.
encountered and surmounted. The general principles
on which the operation is to be conducted, have been
amply set forth in numerous works.
1st STAGE.
The surgeon before he commences an operation for
strangulated hernia, after having deter-
mined the kind by the anatomical relations
of the protrusion, has still many things to consider,
some of these may be estimated before, others only
during the operation.
First for the surface. The state of the scrotum in in-
guinal hernia may afford some criteria. If
Indications
of the scrotum.
from the state it is red and inflamed, so will be the in-
vestments beneath, and probably the con-
tents, and a good deal of troublesome hæmorrhage may
be calculated on. If it is dusky, it indicates a state
within, bordering on gangrene. If, on the first incisions,
a putrid odour is perceived, gangrene will have com-
menced. If a fæcal odour is perceived, cæcum probably
will be found, and this is not to be confounded with the
putrid smell of grangrene; such at all events has been
my own experience in scrotal hernia.
The existence of omentum may often be recognised by
the feel; but it is very liable to be confounded with
layers of granular fat, especially in the thigh, of this I
have seen some remarkable examples, and there are cases
on record in which this has been cut away under the
persuasion of its being omentum. If, however, omentum
presents itself, it is a safe point on which to make an
incision.*
*Mr. Prescott Hewitt has given some very interesting cases, where the
omentum surrounded the intestine as a quasi sac, and Mr. Lawrence

OPERATION BY OPENING THE SAC.
21
and
Extreme vari-
of the invest-
ety in the state
ments.
Great
Investments afford another point of difficulty. By
pinching up all that intervenes between the surface of
the absolute tumour, some judgment may
be formed of the thickness of the common
integuments, but when we come down on
the tumour itself, nothing can be more uncertain.
labour has been bestowed on the anatomy of those
which are purely normal; but, although they may be
assumed to exist in every case, their relative thickness,
and the number of additional cellular laminæ, especially
in femoral hernia, often produces great perplexity. In
some cases they are altogether so thin, that the operator
comes down at once on the contents; in others they
are multiplied, and very thick; and the worst of it is
that, contrary to all reasonable expectation, they are
sometimes thick in comparatively recent hernia, and thin
in those which are old; and the same observation
applies to the young subject and to the old. Again,
while some are thick, others are thin, in the same hernia.
And of the sac itself, it may be said, that while it is not
unfrequently of such tenuity, as to resemble a soap-
bubble, to use Sir Charles Bell's illustration, and so
transparent as to transmit the appearance of
the intestinal surface, in many instances,
very thick,
Great difficul-
by the imme-
ties presented
diate invest-
ments in many
cases.
on the contrary, it has become
and even almost cartilaginous, and stood
open when divided. On the diagnostic signs of intes-
tine, sac, and fascia propria, I offered some observations,
(pp. 309, et seq.) has also adverted to the various ways in which omentum
complicates, not unfrequently, these cases, and produces extraneous stran-
gulation.

22
OPERATION BY OPENING THE SAC.
which were honoured by publication in the first volume
of the Provincial Medical and Surgical Transactions.'
On this point, I shall only say, that I not only shewed
from my own cases, but from the works of Sir A. Cooper,
Sir Charles Bell, and Scarpa, that we may have adhe-
sions of fascia superficialis to fascia propria, of fascia
propria to sac, or of sac to intestines. A mistake in
this matter may lead to a puncture of intestine where
the sac has been divided without having been recog-
nised, and the intestine treated as sac; or where, as
may unavoidably happen, the sac itself thin has ad-
hered to the intestine, and both being raised on the
forceps have been divided together. This, at most,
amounts to a puncture, and may be easily secured by
passing a ligature round it; but even this is not a
matter of indifference, and cannot be too carefully
avoided; it is, however, a very different affair from the
gash sometimes made into the intestine in dividing the
stricture, a misfortune not easily remedied, and often
fatal. Mr. Erichsen has proposed, in opening the sac,
if difficulty occurs, the plan of raising the presenting
part on a hook, where it cannot either be pinched up by
the fingers, or the forceps; and it ought to be borne in
mind; a hook is always at hand in the shape of a
tenaculum.
As regards the fluid contained in the sac, it is a most
Fluid in the important protection to the bowel; and
sac as a pro- as a sign that the true sac has been opened,
operation. is generally, but not always, an indication.*
When it exists in quantity, its presence can often be
tection in the
* Case 22, "Recoveries."

PATHOLOGY OF THE CONTENTS.
23
predicated before the operation, both from the feeling,
and from another diagnostic sign, very important but
often very deceptive. The surgeon during the taxis
may have reduced a part of the tumour. He may
think he has reduced intestine or omentum,
whereas it is neither the one nor the other;
Often decep-
partial reduc-
tive as regards
tion.
The state of
the parts at the
ring the only
reliable indica
tion.
it is fluid. Intestine rarely goes up without
a gurgling sound, omentum does; but it appears to me
that it goes up in bulk, and rarely comes down again,
while fluid is slowly emptied, and presently returns.
The tenderness, pain, and hardness at the ring remains
the same.
The hernia has not been reduced even in
part. Whatever promise the tumour itself
may hold out, as regards tenseness, or
tenderness (and it varies much), the state of
the parts at the ring affordsthe only reliable indication.
There are other considerations which I would venture
to offer, as connected with this subject. If
the fluid can be returned, it argues that the
stricture is not of the closest nature. If
no reduction in bulk is made by the taxis,
it argues either that there is no fluid in the sac, or, if
there is, that the stricture is too close to allow it to
pass.
Further indi-
cations offered
by the presence
or absence of
fluid.
also indicates
conges-
mere
tion on the one
The condition of the fluid is not without significance.
It may be limpid, indicating mere obstruc- Its condition
tion, or otherwise, showing inflammatory
processes. Again, when the stricture has
been divided, it not unfrequently happens
that a gush takes place from the abdomen;
the inference clearly is, that there is active congestion,
hand, or in-
flammation on
the other and
its kind.

24
PATHOLOGY OF THE CONTENTS.
or, it may be, inflammation of the peritoneal cavity;
in this event, the more the fluid departs from the cha-
racter of serum, the worse is the indication; so, too, of
the quantity, which is sometimes so great, and so deep
in colour, that it alarms the operator lest it proceed from
hæmorrhage. It not unfrequently happens that when
the sac contains little or no fluid, the abdo-
men may much. The reason I take to be
this: That the processes of inflammation are
in abeyance below the stricture in consequence
of its extreme tightness, while from the same
cause they are in greater activity above.
Inference to be
deduced from
the sac con-
taining little or
no fluid, and
the abdomen
much.
When fluid exists in the sac, it would always afford a
safe point for opening if it can be in any way ascer-
tained; but it may be only in very small quantity; and
it may be only in part of the sac; and this must neces-
sarily be the case when there are adhesions. In scrotal
herniæ, it is most likely to accumulate in quantity at the
bottom; but that is not a place where we choose to
make an incision. Pressure, however, from the bottom,
may force it into a less objectionable part.
On the nature and pathological anatomy of hernia,
The pathology great labour has been bestowed, with the
of hernia less exception, perhaps, of the contents, but to
attended to the changes which take place in the pro-
of the contents
than the ana-
ral structures
tomy of natu- truded parts an equal degree of attention
concerned in it, has not been paid; where, however, it
although highly
has, that attention has brought its full
important in
various ways.
amount of important information. Thus,
the changes which arise from the nipping of the bowel
at the point of stricture, of late duly noticed by many

PATHOLOGY OF THE CONTENTS.
25
eminent pathologists, and by none more ably than by
Mr. Lawrence, will probably be found to produce, when
all the bearings are considered, more practical influence
on the results of the operation than any other circum-
stance whatever, except lapse of time, with which, indeed,
it is immediately connected; but the changes in the
bowel below are well worth attention. These also
depend upon the duration and degree of the stricture.
If that be extreme, the parts perish as if tied by a liga-
ture (the gangrene of obstructed circulation). If the
degree is less, they may inflame,* that inflammation
running into gangrene from difficult circulation. In a
less degree, we have lymph effused on the surface or
adhesions. In a still less degree, the state is simply one
of congestion, bordering on inflammation; and in pro-
portion as the approximation is greater or less, we have
red or turbid fluid, or simple serum. If inflammation
has not been established, the surface of the bowel
remains polished; if inflamed, often otherwise; and
this test of the presence of bowel during the operation,
much relied on, loses in some degree its value. I had
a case (No. 26, Recoveries), where the effused lymph had
become cedematous; and a similar case is related by
Mr. Lawrence, page 17. In cases of long or severe
strangulation, ulceration at the strictured part may be
the result, as stated above, and the bowel may give way
at the time that is divided, or afterwards, and more
fatally, within the abdomen. If it does not give way, it
The stricture
*The intestines which have descended have been commonly spoken of as
inflamed: in some cases the stricture is so tight that they have not power
for inflammation.

26
DIVISION OF STRICTURE.
still may maintain the obstructed state of the canal,
rather from suspending the downward action of the
bowel, than from absolute narrowing, though to a certain
extent existing, (a circumstance, however, which appears
to have originated Mr. Travers's strong impression that
the bowel was paralysed). Furthermore, by so doing,
and exciting inflammatory action in its new situation
within the abdomen, it is an influential cause of the
peritonitis so often fatal. The bearings of this im-
portant fact on the result of both operations, will be
hereafter adverted to.*
2D STAGE.
stricture.
The preceding observations bear much on the diffi-
culties which present themselves in the first stage of the
operation, the opening the sac when that is
Division of the the purpose; the next is the division of the
stricture or strictures. The remarks I
have to make will chiefly apply to femoral hernia.
Some surgeons of the highest eminence dwell much on
the production of the stricture by different fascia, cinc-
tures of condensed cellular substance, &c., as well as the
well-known fascia and ligaments; it would be presump-
tion in me to doubt such authorities, but I am bound to
say that in all the twenty cases of femoral hernia on
which I have myself operated, I found the stricture
corresponding with the edge of Gimbernath's ligament,†
*It is with reference to that part of the subject that this brief descrip-
tion is chiefly given. This statement is founded on my own observations.
It differs not much from that given by Lawrence and Erichsen.
† Mr. Luke, in his important memoir, adverts (pp. 112, 113) to the
stricture in femoral hernia having been frequently produced by bands of the
fascia propria. It is possible, but I think barely so, that I could have
mistaken the edge of Gimbernati's for this, in the cases I have related.

DIVISION OF STRICTURE.
27
0250
and relieved by dividing that in every case but one, and
that was No. 21, Recoveries, when a large mass of
omentum could not be returned and Poupart's ligature
was also partially divided to free the constriction. It
may s
savour of presumption in me to condemn the use
of the director, but it is liable to grave ob- Objection to
jections; and I have seen the intestine the director.
wounded several times when it has been employed,
(unless the escape of fæces in these cases may have been
owing to the gut giving way at the ring when the stricture
was divided ;*) even the deep-grooved curved director is
but an insufficient guard when the intestine is tense and
the folds turn over; granting also the aid of an efficient
assistant (not always to be obtained). Directors with
wings, or a spatula as proposed by Mr. South, may be
employed to lessen the danger, or a plan which many
years since I suggested when assisting one of my col-
leagues. The sac contained a knuckle of intestine. Two
fingers of the operator had kept it back. The A plan em-
ployed to make
director having been introduced in the groove it safer.
between them, I kept the handle firm, while he easily and
safely divided the stricture with a curved bistoury.
I may suggest that there is another source of danger,
which, as far as I can find, has too much escaped obser-
vation, and is not sufficiently guarded against; namely,
that as there is not only intestine below but above the
*The recommendation we so constantly meet with, of drawing down a
portion, is not free from doubt. The bowel above the stricture is commonly
dilated; if the stricture has existed long, and been very close, nipping the
bowel till it has been softened, it may give way if any, but the most moderate,
force be employed..

28
BOWEL ABOVE THE STRICTURE CONSIDERED.
of the bowel
above the stric-
ture a not un-
frequent cause
of disaster pro-
bably, but not
attended to
hitherto.
Distended state stricture, and as that is generally much dis-
tended by flatus, it will be exposed to mis-
chief, not sufficiently guarded against by
the director and knife as commonly used;
and I am inclined to think, that when the
gut is wounded in dividing the stricture,
it is as often this part as that below which suffers. I
may be permitted to mention the mode I have adopted
to obviate both these risks. Great as the difficulty
sometimes is, it rarely, perhaps never, happens, that the
surgeon cannot feel the edge of the stricture. Having
insinuated the very point of my finger, I pass a narrow,
strong, probe-pointed bistoury, guarded very nearly to
the end, taking care that its edge is sharp. Passing
this with its flat side, as soon as I have got its extremity
Method adopt into the edge of the stricture I turn it,
ed by the au-
thor in divid- press its back into the pulp of my finger,
press the point of that, so armed, against
the edge of the stricture, carefully avoiding any sawing
motion, but cut as it were with the finger itself; this
safely divides a small notch, and allows the finger to be
passed sufficiently far to protect any subsequent division
which may be required. In all the operations, save one,
which have fallen to me, I have pursued this method,
and have never met with a single misadventure.
ing the ring.
While on this subject I may mention my persuasion,
that if the stricture requires division it is not desirable
to limit that to the small extent recently recommended.
A free opening enables the surgeon to return
Advantages of
free division of the intestine with less force; it enables him
to return omentum, which he might not
stricture.

QUESTION OF ACTIVE CONSTRICTION.
29
otherwise do; it enables him also to pass his finger freely
into the cavity of the abdomen, to ascertain whether
there is any further cause of obstruction. As regards
the opening the sac at this point, it can make little dif-
ference whether it is a line or two more or less, and with
reference to any future occurrence of strangulation, it is
very rare, as appears from the statistical records. I only
had one case myself, and that was congenital, nine years
having elapsed. (No. 19, Recoveries.)
Question as to
active constric-
tion by the
As regards the stricture itself, I may be allowed to
offer a few observations. Is there active
constriction? High authorities have pro-
nounced in the negative; but it may be ring.
doubted whether these do not rest their opinions more
on assumption than absolute proof. It is said, the ring
itself is not muscular, therefore it cannot contract; but
do no parts contract which are not muscular? a name
often blinds us to facts. We have been long accustomed
to connect contractile power with muscular structure,
but let us take another case of strangulation, that of the
glans penis in paraphymosis; the stricture here is un-
doubtedly caused by common integuments. [I may
mention two collateral but more doubtful
arguments, in favour of the opinion that
the constriction is active. First, the great
difference there is in the degree of constric-
tion in different cases. Secondly, the great difference
between the feel of the edge in the dead subject and in
hernia.] If it be said, that it is both in this and hernia
merely a chord bound round, and that the effects are
owing to the engorgement of the glans; the answer is,
Analogies
which support
the opinion of
active constric-
tion, especially
paraphymosis.

30
QUESTION OF ACTIVE CONSTRICTION.
that empty the glans as you will, either by cold or
pressure, it will still be found, in most cases, that you
cannot reduce it; but if the patient is rendered faint
it can be returned, just as in hernia; or, that failing,
the stricture must be divided as in that malady. What
applies to the one case, I apprehend may fairly be applied
to the other, and faintness serves, both in hernia, and
in paraphymosis. The auxiliary means in the former,
in aid of the taxis, are largely based on this-bleeding,
warm-bath, tobacco, chloroform, &c. I may further
mention, that in every case of femoral hernia I have
operated on-and for the most part in inguinal-on
dividing the edge of the stricture I have been aware of
precisely the same sensation as is communicated to the
hand in any subcutaneous operation, when the part
divided is rendered tense by well-ascertained active
contraction.*
Statement of
practice.
A few additional observations as to the results of my
own experience may not be out of place.
the proportion- The mortality in my private practice, as
ate mortality
in the author's compared with hospital, has been briefly
alluded to; it is a point on which I should
wish to make some further remarks. The proportion of
deaths to recoveries was 6 out of 12 in the former,
8 out of 24 in the latter. In the former, I met with no
misadventure whatever in the operation, nor was there a
moment's unnecessary delay after my arrival. One
In cases of tapping either abdomen or hydrocele, the resistance made
to the withdrawal of the canula by the clipping of the skin must be familiar
to every surgeon.

MORTALITY OF CASES AT A DISTANCE.
31
cause of this difference appears to be the following. Of
these 12 cases 10 were at a distance; and of the 6 who
died, all but 1 were (as some always will be) of a con
dition of life which while it precluded them from the
advantages of a hospital, did not dispense with pecu-
niary considerations; hence, consultations, the operation
deferred till the last moment (one great element of
danger), and subsequent visits avoided. The distance,
also, from the family surgeon; the want of experienced
nurses; and errors from the interference of friends, all
contribute to lessen the chance of success. I have
been informed that the results of private practice in
London are at least as favorable as of hospital, but in
London the adverse conditions do not apply. It will
be seen, by a reference to the table of deaths in private
practice, that in No. 1 the intestine was in a state of
gangrene when the operation was performed. That in
Nos. 3 and 4 erysipelas and gangrene of the scrotum
supervened, and added to the danger. That in No. 6
severe peritonitis existed prior to the operation; and
that No. 5, a case which appeared to be going on
satisfactorily, died at the expiration of three weeks, from
a recurrence of the symptoms.
Early restora-
tion of the ac-
tion of the bow-
els in the suc-
As regards the 22 successful cases, it will be found,
and it is a fact especially important, that there was, with
little exception, an early restoration of the
downward action of the bowels; while in
the fatal cases it was generally otherwise.
There has been a remarkable change in the
opinions of the profession connected with this point.
Surgeons now are much disposed to leave this matter to
cessful cases,
and vice versa.

32
PATHOLOGY, AS REGARDS SECRETIONS.
Examination
of the facts and
opinions relat-
ing to the em-
ployment.
of
medicines act-
ing on the ali-
mentary canal.
nature, while formerly they were very solicitous to obtain
evacuations, and doubtless founded their
opinions on the fact, that where these took
place early the patient recovered, and their
practice was the corollary; the probabilities,
however, will appear to be, that the bowels
acted because the conditions were favorable,
and if they had given aperients the benefit was attributed
to these in a greater degree than was warranted; but
they were men of far too high ability to allow their
opinions or practice to be lightly regarded, and it may
be supposed that they were partly right as well as
wrong. I may be permitted to remark, that their suc-
cessors also may have been led to form incorrect conclu-
sions, from a similar misinterpretation; thus, although
no aperients whatever may have been given, it is very
certain that the alimentary canal, even after, as well as
before the strangulation is removed, often pours out
large quantities of secretions which are vomited. If
purgatives had been given I suspect they would have
unjustly borne the blame. It will be recollected that
from the moment of strangulation, not only is the action
of the muscular coat inverted-but of the mucous coat
increased and perverted-hence the quantity of secre-
tions thrown from the mouth, until the obstruction is
relieved; and hence, after the operation, the amount of
vitiated matters, remaining in, and still secreted from the
mucous membrane, and which must be got rid of by
the efforts of nature or art, either upwards or down-
wards. Again, many patients remain after the opera-
tion in a doubtful state for days, and during the whole

PATHOLOGY AS REGARDS SECRETIONS FROM CANAL. 33
time there is no stool. The patient may die or re-
cover; if he dies, and aperients have been given, albeit
without effect, they are deemed the cause; but die they
often do when none have been given, and that, too, with
a scourging diarrhoea.* As far as my own experience
goes, it is rarely desirable to give aperients by the
mouth, but very useful by enemata or suppositories, or
to use the long tube, so as to solicit the normal action of
the canal; and if once that action is restored, mild
aperients by the mouth are often given with great ad-
vantage, and of these the best, probably, is sulphate of
magnesia. This is apart from the consideration of com-
bating peritonitis by calomel and opium, and apart also
from the question of giving opium independently in
these cases. When the action is antiperistaltic, opium
by the mouth will often reverse it, still more when given as
an enema, and not only in strangulated hernia, but in
ileus and other inflammatory conditions of the abdomen.
Opium so given, if I may be allowed the expression,
becomes the best purgative, as stimulants are often the
best antiphlogistics in many species of inflammation.†
What are the causes of death after the
operation? In the great majority of cases
peritonitis, often combined with enteritis,
Examination
into the causes
of death after
operations for
strangulated
hernia.
* It is truly observed by Mr. Bryant, that a copious stool and fatal
collapse often go together. (Guy's Hospital Reports,' 1856.) He im-
putes the collapse to the stool; but may not the stool be the consequence
of the collapse ?
† In 1821, when I advanced this position, there were few members of
the profession who would endorse it ('On the Principles of Inflammation,'
&c., 2d ed., pp. 180-187). Not so now.
3

34
CAUSES OF DEATH AFTER OPERATION.
aggravated very frequently, if not produced, by a
continuance of obstruction still existing within the
abdomen, or by the abnormal condition of the hernia,
The omentum remaining)
even if wholly returned, still more if partially. The
most frequent cause, probably, is, that
arising from the portion nipped by the
Briefly stated.
stricture.
The peritonitis
from hernia
differs from or-
As regards this peritonitis which is so often the cause
of death in strangulated hernia, I may be allowed to
observe that there are some material points
of difference between it and ordinary peri-
dinary idiopath- tonitis. The symptoms of the latter are
ic peritonitis. generally clear and well marked from the
beginning; in this, on the contrary, while the symptoms
of obstruction are clear and decided, those of peritoneal
inflammation may not show themselves, if existing; and
it is difficult to say when they do or do not exist.
In hernia there are two orders of symptoms: one
arising from obstruction, namely-constipation, vomit-
ing, hiccough, and pain at the pit of the stomach or
navel; the other those of peritonitis more especially, as
tenderness, pain, tension of the abdomen and pain
at the navel, and in an advanced stage, tympanitis; but
the pulse, so important as an indication in idiopathic
peritonitis, here varies so much as to be of
and degree of little value, and the first order of symp-
mine different toms, not essentially inflammatory, still
degrees, which continues. Now take the case of hernia:
ed into three, the taxis succeeding all the symptoms
producing very
different re-
cease, generally at once. Did peritonitis
The duration
stricture deter-
may be resoly-
sults.
exist? If it did, it must have been so

CAUSES OF DEATH AFTER OPERATION.
35
Effect of the
stricture in su-
perseding the
of the symp-
toms of perito-
usual character
nitis, which are
masked, as it
were, and not
declared, al-
though really
existing. The
latent perito-
nitis of some
authors.
slight as to fade away when the cause was removed.
The taxis not succeeding, one of the operations is per-
formed. If we now have peritonitis, it would be hard
to say that it had or had not existed before the opera-
tion. If not, the chances of recovery would be great;
if it had, they would be less in proportion
to its degree. The difficulty of diagnosis
consists in the fact, that the especial symp-
toms do not disclose themselves, although
extensive peritonitis is often found after
death, even in cases where it has been little
suspected; a circumstance very unusual in
idiopathic peritonitis. This leads to another
and by no means unimportant point: it is
the application of these facts to the subsequent history
of these cases. The operation may have been performed,
the primary cause (without which recovery is rare) re-
moved, but it cannot be said that in all cases "the
effect surceaseth still;" on the contrary, the temporary
relief which consists in the cessation of the pressing
symptoms, arising merely from the constriction, is fol-
lowed at no distant period by those of peritonitis, which
in many instances had in reality preceded the operation,
but was kept in abeyance, so to say, by the depressing
influence of the strangulation (the latent peritonitis of
some authors). That having been removed, after a short
interval the peritonitis developes itself, and
the occurrence of the symptoms, then, leads
to a wrong conclusion. It is often attri-
buted to the operation, or the misapplication
of remedies, albeit it existed before in a
Probably leads
to false conclu-
sions as regards
the operations
the
for hernia and
remedies
employed. The
true conclusion

36
CAUSES OF DEATH AFTER OPERATION.
highly import-
ant as regards
treatment.
masked form.* These remarks are not
merely speculative. They bear importantly,
not only on the foregone conclusions stated above, but
also upon a point hereafter to be considered, namely,
the causes of mortality after both operations-that by
not, as well as by, opening the sac. They further bear
immediately on the question of treatment, for we must
not be lulled into a false security by the apparent relief
afforded by the division of the stricture. Peritonitis
may develope itself after an interval more or less long,
but it is the early indications which it is most important
to watch and to meet.
The type low.
Peritonitis, whether it has existed before or occurred
subsequently to the operation, if not complicated with
irremediable conditions, may and often does yield to
appropriate treatment, but its type is com-
monly low, from the degraded condition of
the bowel, as low inflammation anywhere will communi-
cate its impress on the whole system. The peritonitis
also is often maintained by the continuance
The peritonitis
often maintain of an internal strangulation, either complete
or incomplete, it may be, from the effects of
ed by internal
strangulation.
an unrelieved stricture in the sac. With
*Mr. Paget gives a different interpretation of the fact, i. e., that in
some cases the symptoms of peritonitis display themselves immediately, in
others more remotely. The first he refers to the local cause; the second,
to blood-disease. (Med. Times and Gazette,' Sept. 15th, 1858.) I need
not say, after the remarks I formerly made on the changes produced in the
blood by accidents and amputations, that I should not be adverse to such
an explanation, were it not that the phenomena appear to me to be much
more satisfactorily explained, as I have now attempted to do. At the same
time every deference is due to his opinion.

CAUSES OF DEATH AFTER OPERATION.
37
the exception of the latter, the cause may depend upon
circumstances beyond our control, or upon such as are cal-
culated to elude observation; e. g., a single small hernia
may be returned, with very moderate force, within its sac
if not opened, if the sac does not adhere to the sur-
rounding parts, and if the sac be thin the fact not dis-
covered. Again, a small recent hernia may come down
behind an old one inclosed in its own separate sac, and
be carried back by a force which correctly returns the
primary and lower portion; and if there be stricture in
the neck of the recent hernia, the surgeon may well be
in entire ignorance of its existence. When the sac
adheres to the surrounding parts, this will hardly occur;
but if the sac be recent, not adhering to the surrounding
parts, but gripping the bowel with its neck, it may very
readily happen. Among my own cases will be found
examples of a hernia returned in this way into the cavity
of the abdomen (not between the peritoneum and abdo-
minal muscles). A remarkable case of internal strangu-
lation by a band of mesentery, high within the abdomen,
and proving fatal ;* and, again, others where the omentum
was stretched down in its natural membranous form,
and had formed recent adhesions to the front of the
bowel, and thereby materially contributed to a fatal
result, by impeding the restoration of its functions, a
condition of such frequent occurrence as to deserve the
notice it has lately obtained.
* Mr. Solly, in the last volume of the Med.-Chir. Trans.,' relates a
very similar and interesting case; indeed they are far from unusual. To
this I shall revert in its place.

38 FREQUENCY OF ERYSIPELATOUS INFLAMMATION
gangrene after
operations for
hernia.
The only additional remark I shall make relates to
Frequency and the frequency, severity, and fatal tendency
fatal severity of
erysipelas and of erysipelas and gangrene, especially of
the scrotum, after the operation for hernia.
The looseness of its texture explains the
frequency of the occurrence of erysipelas; but, as far as
my own experience goes, that is much more prone to
run into fatal gangrene than it is after any other opera-
tion in this part. I have myself never known a fatal
case after castration, or the removal of a cancer scroti;
and I have known many instances of recovery even after
urinous infiltration. It is not improbable that the con-
dition of the viscera after their return, especially in the
parts contiguous to the ring and continuous with the
external wound, may exert an evil influence. Inflam-
mation of the external parts consequent on the opera-
tions for strangulated hernia appears hardly to have
received the attention it deserves; and I, therefore, state
the facts which the examination of my own cases dis-
closes.
ઃઃ
In the table of recoveries, twenty-two in number,
there occurred, No. 2, "sloughy abscess of the groin;
No. 12,
troublesome suppuration;" No. 20, "wound,
erysipelatous and sloughy;" No. 6, "great swelling of
the scrotum."
In the table of deaths in private practice, out of six
cases No. 3 had " erysipelas and gangrene of scrotum;"
No. 4, " erysipelas of scrotum."
In the table of deaths in hospital, out of eight cases
there were, "erysipelas," Nos. 3, 4, 5, and 8; also, in
No. 6, "extensive sloughing in the iliac fossa and upper

IN EXTERNAL PARTS.
39
part of the thigh;" so that out of thirty-six cases there
were eleven who had this form of diffuse inflammation,
and two had the erysipelas showing itself also in distant
parts, proving the contamination of the blood. Two
others, whose death was very speedy, might not impro-
bably have proved additional cases had they lived
longer.
If all these had occurred about the same time, it
might have been supposed that they arose from some
epidemic constitution; but when it is considered that
they were spread over a long period, and presented
themselves in various situations, this cannot be ad-
mitted as a cause. That the disposition is more fre-
quent than is, perhaps, generally considered, is further
borne out by the record of cases quoted hereafter from
the Medical Times and Gazette,' and it may be sug-
gested that a more attentive investigation of this subject
is called for.
6
If erysipelas of such an untoward character is a fre-
quent result of these operations, it is a fit subject of
inquiry why it is so-what are its in- The causes
fluences; and how best obviated. Erysipelas suggested.
is, in fact, but a name for a kind of inflammation which
has many varieties, but is essentially the same in all.
Its essence consists in the failure of the adhesive, i. e., the
limiting process-its character to effuse sero-purulent
fluid upon or under the surface, and, from want of
adequate power, to mortify.
In hernia, whatever may be the power of the indi-
vidual, the strangulated parts are, ipso facto, deprived
more or less of theirs, and when returned into the

40
CHARACTER OF THE INFLAMMATION.
abdomen are, for a time at least, in a low state of
inflammation. The external wound offers a continuity
of surface, and if this is not speedily interrupted by the
adhesive process, the type of inflammation of these
returned contents is extended to the external parts, and
hence the low character of the inflammation there,
which, if not speedily met, spreads, and spreads in the
form of low erysipelas.
Again, while such is the influence communicated from
within, the external inflammation will, by the same rule,
reciprocally produce a lowering type in the inflammatory
processes going on there, and augment a risk already
but too great. Such I believe to be the true import of
such cases.*
ted to prevent
What, then, it may be asked, are the rational means
What mea- of reducing these risks? In the first place,
sures calcula- I should say, Petit's operation, when prac-
ticable, for it leaves the sac as a barrier
between the external wound and the hernial contents;
and, furthermore, the small incision usually made is less
liable to such inflammatory processes.
it.
Again, when the sac has been opened, or in any case
where, on the division of the stricture, fluid has passed
from the abdomen, indicating inflammatory action going
on there (always, be it remembered, of a low type),
* In speaking of the phenomena of inflammation, as connected with the
present subject, I have not adopted new terms, which to me appear not
more expressive than the old, and I may perhaps be forgiven for adding,
that there is much reason to think that pathologists of late have been too
much engrossed "in minimis," to the neglect of those great principles
governing the animal economy which are of paramount importance.

CHARACTER OF THE INFLAMMATION.
41
care should be taken not to block up that fluid, especially
where the sac has been opened, for nothing tends to
aggravate the evil so much as keeping corrupt secretions
pent up. Furthermore, the external inflammation should
be promptly treated by those means which best combat
erysipelas, and which, as I have elsewhere endeavoured
to state, I need not now repeat; but I should wish to
impress this illustration-that as a fire is more difficult
to control the more it spreads, so is a spreading in-
flammation.
I shall now proceed to give the whole of my own
cases, in the tabular form before stated; and first, the
recoveries, both in hospital and private practice; secondly,
the deaths in private practice; thirdly, the deaths in
hospital practice, and the autopsies when they could be
obtained. In private practice I am unable to give one;
for which this reason may be assigned, that great
popular objections exist in this part of the country, and
they occurred among a class in which these are very
strong, and, as all were at a distance, there was a greater
difficulty in combating them.

No.
Date.
Kind.
Age.
Sex.
TABLE I.
RECOVERIES.
Duration. Strangu-
Vomiting.
Constipation.
lation.
Tenderness Tenderness
of belly. of rupture.
Contents.
1
1821
Oct. 18
Private
Scrotal 60 M Many years Three
days
Yes
Yes
Yes
Yes
1822
2
Aug. 29 Femoral 35 F
Five days Stercoracious
Yes
Yes
Hospi-
tal.
Bowels
moved after
Operation.
1825
3
Oct. 18
Scrotal 45 M Quite recent Three
Hospi-
days
Stercoracious
and hiccough
Yes
Yes
tal.
Great color, Intestine only.
tending to A part of the
livid
The same
night
circumference
gangrenous
Remarks.
Intestine only Following
day
Omentum only Following
day
An old hernia, and he had worn
a truss. Investments were thick,
excepting sac, which was thin.
Stricture in the external ring,
Little fluid. A shattered and gouty
constitution, and saved with diffi-
culty.
Went on very well for three or
four days. A sloughing abscess
then formed in the groin; part of
the sac and omentum sloughed, and
fæces were discharged. Oct. 10th,
discharged "quite well."
The operation was performed
eight hours after admission. He
at first refused consent. Tobacco
clyster was tried, and produced
great collapse, which was overcome
by internal stimuli, and hot stimu-
lating fomentations to the part.
Although recent, many layers.
Considerable quantity of fluid, high-
ly offensive. Extensive and diffi-
cult adhesions. The whole intestine
returned, including a portion of its
calibre which was gangrenous.
Great relief from the operation.
On the 22d, fæces appeared at
the wound. On the 24th, they re-
sumed their natural course, after
which everything progressed fa-
vorably.
Within
It was a large hernia, and Pou-
twelve hours part's ligament could not be felt.
Supposed, at first, to be inguinal.
Sac so thin, that at first it escaped
being opened, as it was supposed
to be intestine which presented;
1826
4
April 12 Femoral 40 F Two years Three and
Yes
ahalf days
Partial dis-
charge
No
Not much Intestine ad-
hering

44
45
TABLE I.
RECOVERIES.
5
No.
Date.
Kind.
1826
Age.
Sex.
Duration.
Strangu-
lation. Vomiting. Constipation.
Tenderness
of belly.
Nov. 16 Scrotal. 18 M Sudden,
Congeni-
tal
Yes
from blow
Thirty
hours
Yes
Yes
1828
6
July 31
Scrotal 67 M
Old
Seven
days
1832
Evacuation be-
fore the opera-
tion, probably
accounted for
by the stric-
ture not being
very tight, and
the reduction
prevented ra-
ther by the
bulk of the cæ-
cum than by
the tightness
of the stric-
ture
7
April 1 Femoral 72 F Four years Five days
Slight
Yes
Tenderness
Contents.
of rupture.
Bowels
moved after
Operation.
Remarks.
Tumour
large, tender
Intestine
Tender
Tender
Cæcum and
appendix
the ring was then freely divided, but
the contents could not be returned
till the sac was opened. There
was then found no fluid, but ex-
tensive adhesions.
April 24th, "Progressing quite
favorably."
None for Tumour extended high towards
two or three the spine of the ilium.
Sac so
days tense that it could not be pinched
up, and this was found to arise
from the quantity of fluid.
Following
day
Not great Not great Intestine only In a few
hours
The testis was in the groin. The
stricture at the inner ring. Its di-
vision followed by a gush of fluid
from the abdomen. Had trouble-
some symptoms at first, but soon
recovered.
Notwithstanding the length of
time strangulation had existed be-
fore admission, symptoms were
not urgent, and warm bath was
tried; that failing, the opera-
tion.
The contents, cæcum and appen-
dix, and a good deal of fluid at the
bottom.
The intestine was a lively red,
showing that the stricture was not
so tight as to prevent a free circu-
lation, and there was a fur of
lymph on the surface. The reduc-
tion was rendered difficult, rather
by the bulk of the cæcum than the
tightness of the stricture.
The scrotum, on the following
day, swelled greatly; but in a few
days, all the symptoms became fa-
vorable, and after the 5th, went on
"perfectly well."
Tumour small. Thick external
investments. Thin sack. Little
fluid. Intestine healthy. No bad
symptom.

46
47
TABLE I.
RECOVERIES.
No.
Date.
Kind.
Age.
Sex.
Tenderness
Duration.
Strangu-
lation.
Tenderness
Vomiting. Constipation.
Contents.
of belly.
of rupture.
Bowels
moved after
Operation.
Remarks.
1832
8
Oct. 6
Private
Femoral 76 F Many years, Two days
irreducible.
Yes
Yes
None
Little
9
Oct. 27
Scrotal 40 M Three days
Private
Three
days
Constant, and No
hiccough
None
A little Omentum only Following
day
1837
10
July 20 Inguinal 64 M
Nineteen
Yes
Yes
Great
Great
Private
hours
11
1838
Aug. 16 Femoral 35 F Five years
Three
days
1842
None
Little
12
Sept. 22 Femoral 70 M
Private
Four days Stercoracious,
Hiccough
Yes
omentum.
Little knuckle
of intestine
1843
13
June 14 Femoral 65 F
Several
Twenty-
years, irre-four hours
Yes
Not stated
Yes
Little
ducible.
14
Oct. 27 Scrotal 27 M Recent,
One day
No
Yes
No
Great
one month.
1846
15
April 15 Femoral
F
Two days
Intestine only Shortly after No bad symptom. Intestine re-
the opera- duced, although previously stated to
tion; free have been irreducible.
Omento-intes- Day of the
tinal operation
Intestine
Large quantity of fluid in the
sac. The rest, omentum, which was
returned.
The contents not in a bad con-
dition. The intestine was returned.
The omentum could not be; it was
left in the wound, which united over
it. He did quite well.
Following Intestine very dark. A little
evening fluid in the sac, a great quantity in
the abdomen. Was four months
pregnant. August 22d, "Wound
healed, quite well."
Large boss of Shortly after
He had troublesome suppuration,
the opera- but did well.
tion
Omentum over In about
intestine twenty-four
hours
There was a band tightly binding
the centre of the omentum, which
was of course divided; the omentum
returned. Little tenderness at the
ring. Symptoms of peritoneal in-
flammation followed, and the omen-
tum sloughed. Discharged in Au-
gust.
Intestine only Not till the A large quantity of bloody fluid
night of the in the sac. Intestines much dis-
29th, and he coloured, and adhesions, although so
was in much recent. It is also again remarked,
danger until that notwithstanding the short du-
that time ration of the strangulation, the in-
vestments were very thick.
Intestine
State of the intestine approach-
ing to gangrene.
April 15th, "Doing well."
May 10th, "Well."

48
49
TABLE I.
RECOVERIES.
No.
Date of
operation.
Kind.
1846
Age.
Sex.
Duration. Strangu- Vomiting.
lation.
Constipation.
Tenderness
of belly.
Tenderness
Contents.
of rupture.
Bowels
moved.
Recent
Aug. 28 Femoral 75 M
16
Private
1848
17
April 9 Femoral
PIO
F Old, irredu-Two days Operation so immediate that
cible in part
the circumstances were not
particularly stated
One day
Yes,
Hiccough
Freely before
the strangula
tion
Little
Little
Small knuckle Free evacu-
of intestine ations
Great
Great
Omento-
intestinal
1849
18
Dec. 15 Femoral 63 F
Old
Two days
Yes
Partial relief
Yes
Yes
Intestine
1850
19
March
Inguinal 40 M Had been
Congeni-
tal
operated on
Thirty
hours
Yes
Yes
Yes
Slight
Intestine
by Mr. Fow-
ler, of Chel-
tenham, nine
years pre-
viously
1850
20
July
Scrotal 77 M Two years Four days
Yes
Yes
Not urgent Not great,
Intestine
but red and
firm
21
1853
April 7 Femoral 50 F Old, irredu-One day
cible in part
Yes
Yes
Yes
Yes
Omento-
intestinal
REMARKS.
Same day
Not till five
days had
elapsed
Following
day
Same day
Investments very thick. Fat
much resembled omentum. Much
bloody fluid. Good recovery.
Admitted in a state of extreme
collapse, but it was not judged ad-
visable to postpone the operation,
which occupied very little time; but
she was barely saved by brandy
mixture. Contents not bad. Much
fluid escaped from the abdomen.
Followed by collapse, and con-
tinued vomiting and constipation.
She brought up two worms. Change
for the better, attributable to an
injection of Tr. opii 3iss on the fifth
day after the operation, which was
succeeded by evacuations.
Much dark fluid. Several inches
of intestine down. Dark. Testis
lying at the bottom, in contact with
the intestine. Investments very
thick. Sac, tunica vaginalis. Stric-
ture rather tight at lower ring;
very tight at upper. 23d, Conva-
lescent.
There was a large and very sin-
gular effusion of lymph on the sur-
face of the intestine, which appeared
oedematous.
The whole length of the inguinal
canal required division.
As regarded the hernia, he had
not a single bad symptom. The
wound became erysipelatous and
sloughy, but he recovered, and was
discharged September 12th.
Mr. Lawrence mentions a similar
case of cedematous infiltration.
Almost im- Division both of part of Poupart's
mediately ligament and Gimbernat's, required
on account of the difficulty occa-
sioned by the adhesion of a part of
the omentum, which could not be
4

50
51
TABLE I.
RECOVERIES.
No.
Date of Kind.
operation.
1858
Age.
Sex.
Duration.
Strangu- Vomiting.
lation.
Constipation.
Tenderness
of belly.
Tenderness
Contents.
of rupture.
Bowels
moved.
22
Jan. 30 Femoral 45 F
Old
Eighteen Yes
hours
Yes
Yes
Yes
Fluid, and
small knuckle
of intestine
REMARKS.
Same day
separated, and was left in situ, the
free division of the ligaments re-
moving all stricture on it. Abdo-
minal symptoms continued, but were
arrested by leeches, &c. The omen-
tum, which remained down, kept
up subacute inflammation of the
neighbouring part of the abdomen.
Discharged, June 16th.
The hernia was
Double sac.
rather large, and the greater part
soft, and not tender; but near the
ring, and deep, was a small portion,
very hard and tender. This led me
to suppose a double sac, which
proved to be the case. On opening
the first, a large quantity (four or
five ounces) of fluid escaped, and
nothing else was seen; but at the
bottom of this was a small portion,
of a dark colour; this, however,
was not free intestine, but was con-
tained in a separate sac, with ex-
ternal investments to the number
of three, which being divided, in-
testine was exposed, and the opera-
tion finished by the division of the
ring and the return of the intestine.
On the division of the ring an ad-
ditional quantity of fluid escaped from
the abdomen. In this case there
can be little doubt that there was a
sac, containing merely a large quan-
tity of fluid, and within it another,
having its fascia propria; both sacs
passing out through the same aper-
ture. Lawrence quotes, from Du-
puytren, a similar case, p. 505.
Troublesome diarrhoea ensued.
This was checked by wine and an
opiate injection, and on the 13th of
February she returned to her ward.
Has since been discharged.

No.
52
Date of
Operation.
Kind.
Age.
Sex.
1839
1 April 17 Scrotal 50 M 15 Miles
TABLE II
DEATHS.-PRIVATE CASES.
Distance.
Dura- Strangula-
tion. tion.
Vomiting.
Constipation.
Tenderness
of belly.
Tenderness
of rupture.
Contents.
Bowels
moved.
Two days
Hiccough
Yes
REMARKS.
1840
2 June 7 Femoral 65 M 14 Miles Four
Little
Great, and
redness
Intestine
Four days
days
Yes, and
Hiccough
Yes
Little
Little
Omentum
1850
3 May 25 Scrotal 60 M 7 Miles
Old
One day
and tense
Not
Very large Omento-intes- Yes, but not
tinal for three
days
Although in a state of great col-
lapse, and the danger imminent, he
would not immediately consent to
an operation, which, however, was
performed four hours after my ar-
rival. The intestine was in a state
of gangrene. He died the next
morning.
In this case there was great diffi-
culty in distinguishing whether fat
or omentum presented itself. There
was no fluid, and the omentum dark,
but not gangrenous. The symp-
toms on my arrival altogether bad.
Sunk countenance, dry tongue, and
hiccough. Pulse small and unsteady,
The operation performed immedi-
ately. It afforded relief for a few
hours, but he sunk and died on the
9th. I did not see him afterwards.
A large coil of small intestine,
dark; the omentum more so. I
removed a portion, which did not
bleed. A large quantity of bloody
serum discharged from the abdo-
men on dividing the stricture, which
was in the outer ring. Relief im-
mediate; but subsequently perito-
neal inflammation (continued), for
which treated by bleeding, &c. On
the 28th evacuations, and state fa-
vorable. Erysipelas and gangrene of
the scrotum came on and caused his
death; (The incision was high up.)
The abdominal symptoms having
subsided. He had also retention
of urine. I did not see him after
the operation.
53

54
55
TABLE II.
DEATHS.-PRIVATE CASES.
No.
Date of
Operation.
Kind.
Age.
Sex.
1852
5 July 3
Femoral 70F 6 Miles Old Two days
Distance.
Dura- Strangula-
tion. tion.
Vomiting.
Constipation.
Tenderness Tenderness
of belly.
of rupture.
Contents.
Bowels
moved.
Yes
Yes
No
Great
4 April 9 Inguinal 54 M 14 Miles Some
One day
Yes
Not stated
Great
Great
Intestine
months
1857
6 April 22 Femoral 60 F 8 Miles Recent Three days
Constant,
fæcal
Yes
Yes
Intestine
Yes
REMARKS.
Omento-intes- Not for se-
tinal
Tongue dark. Aspect bad. Pulse
veral days little distended. On opening the
sac, a little dark grumous blood es-
caped. Omentum and intestine
both very dark. There had been
no evacuations on the 7th, and I
recommended a suppository with
croton oil and aloes, which succeed-
ed. On the 15th, twelve days after
the operation, I had a letter from
her medical attendant, stating that
she was going on quite favorably;
but on the 17th another, stating
that there had been a relapse, and
she died. I did not see her after
the operation.
No
None
Tumour very tense. Much fluid.
Immediate relief from the division of
the stricture; this continued for
twenty-four hours, when symptoms
of acute peritoneal inflammation
required bleeding, &c., but did not
succeed; and to this, erysipelas of
the scrotum was superadded, which
rapidly became gangrenous, and on
the 17th he died.
I saw him again on the 13th.
The patient did not disclose the
fact of her having a hernia, and the
symptoms were treated as perito-
nitis, until the discovery was made
on the morning of the 23d, when
I was sent for. Relief followed
the operation, but the vomiting
never ceased, and she died about
two days after the operation.
This was one of the cases of
large femoral hernia overlapping
Poupart's ligament, and much re-
sembling inguinal.
It contained about four inches of
intestine, adhering extensively to
the sac; the adhesions quite recent,
and broken down by the handle of
the knife. The colour of the in-
testine not particularly bad.

56.
67
No.
Date.
Kind.
Age.
Sex.
TABLE III. DEATHS.-HOSPITAL.
Duration. Strangu- Vomiting. Constipation.
lation.
Tenderness
of belly.
Tenderness
of rupture.
Contents.
Bowels
moved.
1
1823
Dec. 20
Scrotal
Young M
Old
18 hours Yes
Yes
Yes, great,
and
tympany
Great
Cæcum
No
REMARKS.
There were many interesting cir-
cumstances in this case. The pro-
truded part was cæcum only, form-
ing a tumour of the size of a small
melon. On dividing the external
investment a faecal odour was per-
ceptible. There was a distinct sac.
There was great difficulty in ascer-
taining the character of the pre-
senting part, for three inches of the
intestine were exposed before a band
presented itself. There was some
degree of stricture in the external
ring, easily relieved, but the cæcum
could not be returned. This led to
further examination, and a band
was felt within the abdomen, which
was carefully divided on a curved
bistoury, as far as it was possible,
without laying open the cavity of
the abdomen. That was tense in the
highest degree, and it was considered
not improbable that the return of
the bulky cæcum was prevented by
it (a not unfrequent cause of diffi-
culty). The ilium could be freely
drawn down and returned, but the
cæcum neither drawn down nor re-
turned, nor the air it contained.
The cæcum was then punctured in
four or five places, with an acu-
punctuation-needle, replaced, and
the wounds brought together. The
man died in a few hours.
The body was carefully examined.
A band was found, nearly but not
entirely divided, situated at two
inches from the anterior spine of
the ilium, in a line drawn from that
to the umbilicus, and it resulted

TABLE III.
59
DEATHS.-HOSPITAL.
58
No.
Date.
Kind.
Age.
1831
Sex.
Duration. Strangu- Vomiting. Constipation.
lation.
Tenderness
of belly.
Tenderness
of rupture.
Contents.
2
Aug. 20 Femoral Middle F Old
24 hours Yes
Yes
Yes
Omento-
intestinal
1832
Bowels
moved.
REMARKS.
Yes, follow-
ing day
from a twist of the bowel (colon).
The complete division was difficult,
even with the parietes freely open,
from the tense state of the intestine
over it. The peritoneum and bowels
above the cæcum highly inflamed;
that, scarcely. The punctures had
completely closed, and no escape of
fæcal matter.
There can be no doubt that it
would have given this man his only
chance, to have laid open the abdo-
men; but it is highly probable, in
its tympanitic state, a volume of
intestines would have been pro-
truded, and never returned.
A very similar case is related by
Mr. Solly, in the last volume of the
Medico-Chirurgical Transactions,"
and there are many on record. In
a similar case I should lay the ab-
domen freely open.
The hernia was large; the upper
part situated in the right groin,
and doubled back; this was omen-
tum, and had been irreducible. In
the hollow of the thigh a small,
globular, tense tumour, Intestine
separated from the former by a very
close band, requiring division. The
intestine very dark; this was re-
turned easily-the omentum with
difficulty. Aperients were given,
and evacuations followed. Twelve
hours after the operation she was
reported "very comfortable;" but
on the 21st bad symptoms returned,
and on the 23d she died, at 6 a.m.
The body was removed the same
day.
Went on favorably at first, but,
speedily on the 24th, erysipelas of the wound,
which increased, and became dusky.
On the evening of the 25th, symp-
toms of peritonitis; and at 3 p.m.
of the 26th, he died, not without
3
Aug. 22 Femoral, Old, but M Old
2 days
Great
hale
Cæcum and
appendix, and
Yes,
ilium

DEATHS.-HOSPITAL.
61
60
No.
Date.
Kind.
TABLE III.
Age. Duration. Strangu- Vomiting. Constipation.
Sex.
lation.
Tenderness
of belly.
Tenderness
Contents.
of rupture.
Bowels
moved.
REMARKS.
1843
4
Jan. 18 Femoral
F 4 days
56
4 days
-
Yes, and
distended
Yes
1852
Omento-
intestinal
Yes
Yes
5
March 30 Femoral
66
M
Old
4 days
Stercora-
cious
Omento-
intestinal
*Lawrence, p. 13, gives example of double hernia passing through a common aperture.
some suspicion of having been af-
fected bythe epidemic (cholera) which
then raged in Exeter, for there was
great blueness of the extremities
and lips. The evacuations, how-
ever, continued fæcal and moderate.
No examination.
Large eva- Sac was very thin; no fluid;
cuations on contents, omentum and intestine,
the 22d smelling badly. Stricture very close,
requiring a large opening before the
omentum could be returned. Vo.
miting continued after the opera-
tion, until the 21st. On the 22d,
erysipelas, and the wound had shown
no action; 23d, worse, and died
at twelve.
Next day
Examination. Peritoneal inflam-
mation. A knuckle of intestine,
dark and strangulated, in the neck
of a sac within the abdomen. The
ring was largely divided. There
was no omentum in this sac.
It was supposed that this was a
double hernia-that the knuckle of
intestine last protruded was first
returned, still strangulated by the
neck of its own sac, and followed
by the return of the omentum.*
It is singular that there should
have been free evacuations on the
22d.
A person who had been in much
better circumstances, and whose
constitution was as much broken
down as his fortunes. He was
eminently bilious.
The intestine was dark, but not
sphacelated. Relief immediately fol-
lowed, and free evacuations the next
day. The abdominal symptoms did
not subside at once, but gradually
improved, under free evacuations
and good support. On the 3d of
Also vide South, p. 4; Chevalier, Med.-Chir. Trans.,' vol. iv, Case 2.

62
63
TABLE III.
DEATHS.-HOSPITAL.
No.
Date.
Kind.
Age.
Sex.
Duration. Strangu- Vomiting. Constipation. Tenderness Tenderness
of belly. of rupture.
lation.
1855
6
March 7 Femoral Middle F
F 1 year,
1
not redu-
cible
4 days
Yes
No Yes
No
Contents.
Bowels
moved.
REMARKS.
Omento-intes-
tinal. Intes-
tine with a thin
expansion of
omentum firm-
ly adhering
No
April there was erysipelas of the
wound, which also appeared on the
opposite hip. At the end of the
third week a little bile appeared in
the discharge. On the 22d, the
sac sloughed away, and about the
same time there was a large dis-
charge of fæces through the wound.
May 6th, a complete fæcal fistula.
In the early part of June, more than
two months after the operation, he
sank exhausted. The body was
removed.
The operation was deferred for
three days after her admission. 1st,
from her own conviction that the
symptoms did not arise from hernia.
2dly, from the absence of tender-
ness in the tumour. 3dly, from the
undoubted, and rather free, eva-
cuations.
A sudden change took place to-
wards the evening of the 7th, and
the operation was performed at
10 p.m.
The intestine, which was very
dark, adhered closely to the sac,
which was also very thin; and
although every care was taken, a
small puncture was made. This was
immediately surrounded by a liga-
ture. The stricture was freely di-
vided. From the state of the in-
testine, it was deemed advisable not
to return it.
For twenty-four hours there was
very considerable relief, but no sa-
tisfactory evacuation. On the 10th,
fæces appeared at the wound. On
the 12th, at 11 p.m., she died.
Examination, 13th. Small in-
testines above inflated; reddened.
No lymph. Had serum in the ab-
domen. The intestine in the wound
had sloughed, and a considerable
portion above was of a greenish
colour. The intestine below ex-

DEATHS-HOSPITAL.
65
64
No.
Date.
Kind.
Age.
TABLE III.
Sex.
Duration. Strangu- Vomiting. Constipatio
Tenderness
of belly.
Tenderness
Contents.
of tumour.
lation.
Bowels
moved.
REMARKS.
1855
Little
Great
Intestine
7
June 17 Femoral 18 F Old 4 days Yes
No
8
1858
May 28 Femoral
45
F Recent
2 days Yes, ster-
Yes
coracious
Not much, Tense, little Intestine.
a little
painful
Began
May 22d.
tumid
tremely contracted. The iliac fossa
and upper part of the thigh in a
sloughy state. The third insertion
had been divided to the spine of the
pubis.
A band of omentum was stretched
down from the stomach to the her-
nial portion of the intestine, to
which it strongly adhered.
It was intended to open the sac.
A distinct fascia propria was di-
vided, and another well-defined layer
under it; what then presented was
doubtful. The preceding case was
fresh in our recollection, and, as
after a free division of the ring, the
protrusion could be returned with-
out any force, this was done. The
operation was late in the evening.
She was not relieved by it, and died
the following day in a state of col-
lapse. The abdomen tympanitic.
Examination, June 19th. Intes-
tines highly inflamed, with scarcely
any effusion. A knuckle of intestine
still bound by the neck of the sac,
though not very tightly, as it slipped
out during the examination. It laid
quite within the cavity of the abdo-
men. The sac thin, and almost
identified in colour with the intes-
tine; no fluid between them. The
state almost gangrenous.
Canal
above distended; below, contracted.
Band of adhering omentum dragged
to the lower inguinal region, but
not within the sac. The ring amply
divided.
Sac not opened. The hernial sac
was soon exposed, and I had no diffi-
culty in passing my finger through
I felt the obturatrix artery lying
the edge of the stricture, which I freely divided.
under it. I now emptied the sac, by pressure on its contents, but their reduction
was not without difficulty. It was effected, however, leaving the sac quite free; not
discoloured; rather thick. This I returned, but it came down again empty; it was re-
placed, when the wound was dressed.
There was considerable febrile action, with flushed face; and frequent, full, and soft
5

66
MORTALITY OF OMENTO-INTESTINAL HERNIA.
REMARKS (continued).
pulse, and copious perspiration; with tenderness in the inguinal and iliac
region; but without any hardness whatever. Leeches were continuously
applied here, in small numbers, for two days and nights. Vomiting con-
tinued for two days, but gradually ceased, and the bowels began to act at
the same time. No purgatives were given by the mouth, except calomel
and opium be so considered, but aperient enemata and suppositories were
employed. When the bowels began to move the secretions soon became
very abundant, dark and fetid, and they were not checked till they began to
show an enteritic character. Aromatic confection with opium, was then
given with decided benefit.
On the 25th. The neighbourhood of the wound exhibited dusky erysipe-
las, which spread. Simultaneously, an erysipelas of the same character
showed itself at the back of the thigh. It was a very unfavorable circum-
stance, that it was necessary, from our operation-wards being full, to re-
move her at once to her own rather over-crowded ward. The symptoms
as regarded the abdomen, at the time of her death, which was at six a.m.,
on the 28th, were favorable, and she was passing healthy stools with
yellow bile.
An examination could not be procured.
Large propor-
tion of fatal ca-
ses of omento-
intestinal her-
nia.
It will be seen from the foregoing tables, that of
the 22 recoveries, 15 were intestinal only;
2 omental only; and 5 omento-intestinal;
but of the 14 deaths, 7 were intestinal
only; 1 was omental only, and 6 were
omento-intestinal; so that out of 22 intestinal herniæ,
only 7 were fatal; but out of 11 omento-intestinal, 6-
a nearly double proportion. For this difference I shall
now endeavour to assign reasons. In merely intestinal
herniæ, the intestine being replaced, is, saving the
changes which strangulation has induced, in a condition
to return to its natural state; but when omentum is
combined, it often happens that a part of the mass
cannot be replaced, or must be cut away; or that the
membrane stretched down from above has formed adhe-
sions to the surface of the intestine, impeding its func-
tion, at the same time dragging down the stomach.
Again, it often forms a dense lump (the result of its long

RETURN OF NORMAL ACTION OF BOWE
67
displacement), which, when pushed into the abdomen
presents a surface the very reverse of that which omentum
is intended to offer. From the tables given by others,
I think the opinion I have now ventured to give will
be confirmed, as to the frequent mortality of this
form.
It will be observed, also, with reference to another
important point which has been more attended to, and
Normal action on the bearings of which I have also ven-
of the bowels tured some remarks in an earlier part of
speedily
re-
cases which re-
stored in the this memoir, namely, the restoration of the
peristaltic action in its normal direction;
covered, and
the reverse in
those which
proved fatal.
that in 20 out of the 22 which recovered,
the bowels moved shortly after the opera-
tion; and in 2 cases (the 5th and 16th), where the
evacuations were late, the symptoms were at first bad.
In by far the larger proportion of those who died, eva-
cuations either did not take place at all, or with diffi-
culty, and at a remote period, showing either that a
mechanical obstruction still existed from some unrelieved
cause, or from changes wrought in the imprisoned bowel
prior to the operation; or from peritonitis existing
before, or occurring subsequently, for in 3 only were
there any speedy evacuations; in 7 there were none,
and, in the remaining 4, several days elapsed before any
took place, and then shortly before death.
I adopted the columns in my tables from those of
Mr. South, and, to a considerable extent, they show that
I had noticed and recorded the existence of more or less
tenderness, either in the rupture itself or in the abdomen,

68
STATISTICS OF HERNIA.
Not safe to ar
gue on the de-
gree of tender-
ness of the ab-
domen or tu-
mour.
but I do not think it would be safe to
attempt any conclusion, even if the number
of cases were much larger. The state is
often uncertain, sometimes contradictory;
thus the tumour may have been tender, and the abdomen
not, and vice versá; but the main source of difficulty is
this: that in several cases the entry was made at the
time the cases came under my care, which in those in
private was just before the operation; while in the others
it was commonly recorded on admission, and not always
followed up till the operation was performed, which,
although generally very speedy, was not always so, on
various accounts; one, but too common, the patient de-
manding the consent of friends at a distance. Another
source of doubt consists in the fact that different people
manifest a greater or less degree of pain and apprehen-
sion when handled. It is no easy thing to guage this.
Statistics are valuable in proportion as the subject-
differ- matter is one capable of being ascertained
in the with more or less certainty. For instance,
tical evidence. a hernia being simply intestinal, or omento-
cided charac- intestinal, is a matter of fact, and so is the
proportion of deaths in each. Again, the
bowels having been moved shortly after the operation,
or otherwise, is a matter of fact; so, frequently, correct
information can be obtained as to the extent and cha-
racter of such evacuations. On such points as these we
have good right to found an argument.*
Great
ence
value of statis-
Some of a de-
ter.
* There are other recent and very important contributions to the
Statistics of Hernia, e. g., by Mr. Ward, who has given a very valuable re-
port of 100 cases, operated on in the London Hospital. ('Lancet,' June 19th,

STATISTICS OF HERNIA.
69
With this I conclude the more immediate results of
my own practice; but there is a subject which remains,
and to which I have before alluded (p. 5), of so much
importance that I proceed to offer some comments upon
it. If it be objected that I have seen but little of the
operation about which I am going to speak, and that it
is not fit that I should discuss its merits, I have one
answer to give, which will not be without its weight;
that whereas if I argued on facts purely my own
they might be liable to challenge, by adopt-
by opening the ing those of others, which are free from
sac compared
with that by misinterpretation, no such objection can
not opening it. Jay and such are the records to which I
i. e.,
The operation
C
have before alluded (published in the Medical Times
and Gazette'), founded on the practice of a large pro-
portion of the metropolitan hospitals for three years,
1856.) The table of Mr. Gay of twenty-two cases, operated on by him,
and published so recently as August, 1858, Medical Times and Gazette,'
is also highly important, as will hereafter appear. Mr. Prescott Hewitt's
cases, in the twenty-seventh volume of the Med. Chir. Transactions,' are
especially valuable with reference to the operation by opening the sac, they
amount to 34; 9 died, 25 recovered. (This paper also contains four very
interesting cases of omentum surrounding and strangling the intestine.)
I am also bound to mention Mr. Bryant's valuable analysis of the cases
which occurred at Guy's Hospital, ('Reports,' 1856.) No doubt
many of
the cases included in the above records, constitute a part of those which
are given during the three years' statistics in the metropolitan hospitals
hereafter quoted, which, as I have elsewhere stated, being of a more com-
prehensive character, were better calculated for the purpose; but they re-
ceive confirmation, rather than otherwise, from the separate reports of the
surgeons above given, and also, as it appears, from those of the provincial
hospitals since added, but which, as yet, are extended over a much shorter
space of time, and where probably Petit's operation has been less generally
tried.

70
AMOUNT AND CAUSES OF MORTALITY
and including that of the most earnest and most able
supporters of Petit's operation. I subjoin these sta-
sistics. They comprise, it will be understood, all the
Arguments cases of strangulated hernia which were
chiefly found-
ed on copious operated on at these hospitals during the
and indepen- space of three years. The recoveries are
dent statistics
of both opera- separated in the reports from the deaths,
tions in the
and Gazette.'
Medical Times but otherwise they are given indiscrimi-
nately. The plan I have pursued has been
to arrange separately those in which the sac was, and
those in which it was not, opened. I next separated the
Mode of analy- fatal cases of each. I then carefully ana-
lysed the results of the last of the three
sis.
years under both heads.
The general summary, then, of the first two years is
as follows: there were 265 operations; the sac was
opened in 179, giving 97 recoveries and 82 deaths;
the sac was not opened in 86 cases, giving 55 recoveries
and 30 deaths.
In the third year the sac was opened in 87 cases;
giving 43 deaths, 42 recoveries, and 2 reported under
treatment; the sac was not opened in 39 cases; giving
24 recoveries and 15 deaths. It will be perceived that
the rate of deaths to recoveries under the last head con-
siderably exceeds that which occurred to particular
surgeons; thus, Mr. Luke lost only 7 out of 59;* but
similar differences in success are to be found in the
history of all operations; and much depends not only
on the skill in the operation, but in the judgment which
selects appropriate cases.
*Medico-Chir. Trans.,' vol. xxxi, p. 103.

AFTER THE OLD OPERATION FOR HERNIA. 71
Object to as-
certain how far
the deaths were
due to the par-
ticular opera-
tion, to
or
pos-
These reports were made quarterly, and I shall take
them as they occur, endeavouring to analyse the fatal
cases in which the sac was opened, with the
view of ascertaining as far as may be
sible, whether the deaths were imputable to
that mode of operating, or to causes beyond
causes beyond the control of surgery; in short, to ascer-
the operator. tain whether, in the cases which died, the
deaths may be attributed to the operation, rather than
the disease, or to any aggravation of the consequences
of the disease by the operation; and if so, whether to a
greater extent than when the sac was not opened.
the control of
Analysis of the
6
The first quarter of the last of these three years is
reported in the Medical Times and Gazette'
cases in which of October 25th, 1856. The sac was
the sac was opened in 12 cases, with 4 deaths and 8
recoveries. On examining the causes of
death in these 4 cases, it may be stated as regards-
opened.
CASE 16.-Femoral. The bowel was found adherent
to the sac; strangulation five days. Death in twenty-
four hours.
CASE 18.-Scrotal. Symptoms very acute. When
the sac was opened an ulceration was found beneath the
stricture. Death from peritonitis in forty-eight hours.
CASE 20.-Inguinal. The intestine was found in an
almost sloughing state, and afterwards gave way within
the abdomen. Death, ten days.
In the last two cases death would in all probability
have occurred, whatever operation had been performed.

72
AMOUNT AND CAUSES OF MORTALITY
In the first, Petit's operation might possibly have suc-
ceeded better, but it is not very probable.
The second Quarter dates January 30th, 1857.
The sac was opened in 17 cases; recoveries 5, deaths
11; 1 remained under treatment.
From the fatal cases the following are selected with
reference to the causes of death.
CASE 12.-Femoral. Strangulation fifty hours; con-
dition urgent. Attempt made to return the contents
without opening the sac (Luke), omento-intestinal. In-
testine returned; omentum adherent, left in situ. Death
from peritonitis fourth day.
CASE 13.-Inguinal. Reduction prior to admission;
strangulation remaining; inguinal canal opened but
nothing found. Autopsy; intestine within gangrenous;
constricted by a band of lymph; peritonitis. Death
following day.
CASE 14.-Femoral. Attempt made to return with-
out opening the sac (Quain). At the autopsy a coil of
intestine was found twisted on itself, and gangrenous.
CASE 16.-Femoral. Strangulation four days; au-
topsy showed the bowel to have given way at the seat of
the stricture.
CASE 19.-Femoral. Strangulation five days; bowel
had given way in two places. Death from peritonitis
following morning.
CASE 20.-Inguinal. Strangulation ninety hours;
symptoms not very urgent; 1 feet of intestine;

AFTER THE OLD OPERATION FOR HERNIA.
73
lymph on its surface; sac sloughed. Death ninety-five
hours after operation. Bowel found congested, with a
thin layer of slough at the seat of the stricture; peri-
tonitis.
CASE 22.-Femoral. Strangulation fifty-six hours;
when sac opened, bowel found nearly gangrenous,
Death next day.
CASE 24.-Kind not stated. Death from internal
strangulation by a band passing over a portion of the
ilium.
CASE 25.-Femoral. Woman; bedridden. Attempt
to operate without opening the sac (Wordsworth,) failed.
All did well as regards the bowel. Death from exhaus-
tion six weeks afterwards. Abscess of the pleura.
Thus, out of 17 deaths, 9 may fairly be accounted for
by circumstances which might well have baffled the
best surgery, whatever operation had been performed.
Indeed, in three, attempts were made to return the con-
tents without opening the sac, and we may be assured
did not fail from want of skill. Nos. 12, 14, and 25.
The third Quarter dates May 30th, 1857.
The sac was opened in 28 cases, giving 13 deaths, 14
recoveries, 1 under treatment.
CASE 11.-Scrotal.
Hernia contained, it is stated,
nine feet of intestine. After it had been reduced it was
forced down again, and could not be returned. The
epigastric wounded but secured. Death in sixteen
hours.

74
AMOUNT AND CAUSES OF MORTALITY
CASE 19.-Scrotal. Operation five hours after strangu-
lation; two feet of intestine down. Death from peri-
tonitis thirty-six hours.
CASE 21.-Inguinal. Strangulation "many hours."
Admitted in a state of collapse, and died in that state
three hours after the operation.
CASE 22.-Femoral. Bowel found gangrenous, and
was laid open. Death eight weeks afterwards, from
inanition.
CASE 23.-Femoral.
2
Abdomen in a state of col-
lapse. Died a few hours after the operation. No
autopsy.
CASE 24.-Femoral.
Omento-intestinal; adhesions
which were separated; intestine black but polished;
returned.
CASE 28.-Femoral. Omento-intestinal. The bowel
was found to have given way through nearly its whole
circumference, Death soon after. No autopsy.
CASE 32.-Femoral. Omento-intestinal. Intestine was
found healthy. Death on the tenth day from bronchitis,
to which the patient had been long subject. Autopsy
showed the bowel and peritoneum healthy.
CASE 33.-Inguinal. Congenital. From previous vio-
lence in the taxis the sac itself had been ruptured; there
was much adherent lymph on the surface of the intes-
tines. Death from peritonitis in thirty hours.
Of the 13 deaths, 9 have been selected as cases where
either the death was independent of the hernia, as in No.
32; or where no other operation was likely to have served,

AFTER THE OLD OPERATION FOR HERNIA.
75
Another, No. 30,
excepting, perhaps, in the first two.
in which it was intended to open the sac, was the sub-
ject of a misadventure, an external layer having been
mistaken for it, and the sac was not opened. Death in
twenty-four hours. The intestine still strangulated and
nearly gangrenous. This case is included in the series
of sac not opened."
66
The fourth Quarter dates October 10th and 17th, 1857.
The sac was opened in 30 cases; recoveries 15,
deaths 15.
CASE 12.-Scrotal. Omentum in a cancerous state,"
and was cut away. Patient died comatose the third day,
CASE 15.-Inguinal. Strangulation eleven hours;
had chronic bronchitis. Death after thirty-nine hours.
No peritonitis.
CASE 20.-Femoral. A woman bed-ridden several
years; had a large bed-sore at the time; the result of
the operation favorable. She died from bronchitis and
debility two months afterwards.
CASE 21.-Femoral. Had erysipelas and pyæmia.
Death three months after the operation.
CASE 23.-Inguinal. Intestine found nearly gan-
grenous. Death from peritonitis forty-eight hours.
CASE 25.-Large scrotal. Child, thirteen months.
Death from convulsions and coma; autopsy showed the
intestine healthy.
CASE 26.-Large scrotal. About six feet of ilium

76 ANALYSIS OF FATAL CASES-OLD OPERATION.
down; almost in a gangrenous state; strangulation only
ten hours, Death from collapse.
Of the 15 deaths in this quarter, 7 are clearly
accounted for, and no other operation would have afforded
a better chance.
There are 2 more which are given with less preci-
sion, but I think they may be considered as additional
cases of death not due to the operation of opening the
sac, namely-
CASE 13.-"Sac opened. The bowel had been reduced
without opening the sac, and omentum only was ex-
posed. The omentum was adherent, and the crural ring
very tense. Death from peritonitis the second day." I
suppose Petit's operation was tried in the first place, and
the intestine was returned, but that the omentum re-
maining the sac was opened. The account is by no
means clear.
CASE 19.-Femoral.
strangulated three days.
66
'very ill at the time."
It is stated that it had been
The patient subject to cough;
Death on the tenth day.
The results of the year may now be briefly stated.
RESULTS.
Total
No. of
Sac opened. Number Deaths.
Probably ac-
counted for.
Doubtfully
given or
under treat.
Recove-
Remain.
ries.
1st Quarter.. 12
4
3
8
1
2d Quarter . 17
11
9
1
5
2
3d Quarter . 28
13
10
1
14
3
4th Quarter . 30
15
7+2
15
6
87
43
29+2
2
42
12

NO ANALOGY BETWEEN PETIT'S OPERATION AND TAXIS. 77
This analysis
The large proportion of deaths is very startling,
amounting to one-half of the cases operated
on; but if I have given a tolerably fair
solution of the 31 cases which died
shows that a
very large pro-
portion
unavoidable
deaths.
were
from causes for the most part beyond the
control of art, and in by far the greater number such as
would have been unfit for Petit's operation, it will leave
only 12 for fair comparison.
This is not the first attempt that has been made to
ascertain the causes of death after the operation, for in
Mr. Lawrence's valuable work will be found a very able
statement on the subject, more recently also by others;*
but, in the present instance, the materials have been sup-
plied from various independent and unbiassed sources,
and they are both ample in number and sufficiently com-
prehensive. I may further observe with respect to the
principal object of this inquiry, that no one of the dis-
tinguished surgeons alluded to, has expressed any opinion
adverse to the alleged analogy between Petit's operation
and that by the taxis, which is one principal object of
this inquiry, but rather the contrary. As regards the
cases now cited, it will be found that peritonitis existed
in a large proportion. In a great many of
these it was clearly traceable to the changes
produced in the protruded contents from
inflammation, gangrene, nipping of the
Various causes
of death inde-
pendent of any
operation.Com-
mon to both.
bowel by the stricture, adhesions preventing the return,
or separated forcibly. Also from causes within the
abdomen, such as bands, or twisting of the bowel; but
* I may particularly mention Mr. Bryant's Analysis of the Fatal Cases
in Guy's Hospital.'

78
AMOUNT AND CAUSES OF MORTALITY
besides these we find erysipelas, gangrene of external
parts, pyæmia, inflammatory affections of the chest,
failure of constitutional power, inability to bear the
shock of an operation or of the disease, bed-sores, &c.,-
circumstances quite independent of the operation, and,
as will be seen hereafter, common to the operation
without opening the sac.*
6
* Since this was written, the paper of Mr. Gay (to which I before
alluded) was published in the Med. Times and Gazette,' August 14th, 1858.
It contains a table which singularly confirms the foregoing views. It de-
scribes 22 cases, operated on by Mr. Gay himself: 11 of these had
the sac opened, 7 died, 4 recovered; 11 had not the sac opened, 4 died,
7 recovered (a sufficient proportion, I submit, if others were wanting, to set
aside any analogy with the taxis); but the remarkable circumstance is, that
of the 7 who died where the sac was opened, death may, I think, be
fairly accounted for, as in the cases I have previously quoted, independently
of any influence from the operation. The following is a brief abstract:
"No. 3. Strangulation had existed twelve days; the contents highly in-
flamed.
29
دو
و"
وو
4. Strangulation had existed ten days. Intestine dark, not
grenous evidently unfavorable.'
gan-
5. Omentum gangrenous. A knuckle of intestine nearly cut
through by the stricture.
6. In a state of collapse. Death in three hours.
12. Omentum and a knuckle of gangrenous intestine in the sac.
17. Died suddenly from disease of the heart, while otherwise pro-
gressing favorably.
19. Hernia protruded by a severe blow, which appears also to have
occasioned large hæmorrhage into the abdomen."
I may
add the important contribution by Mr. Ward, who gives the result
of 100 operations performed in the London Hospital by different surgeons,
as follows: out of 63 cases of femoral hernia, the sac was not opened in 42,
of these 10 died. Of 21, where it was opened, 9 died; but the ages of the
patients, and the periods of strangulation, appear to have been much less
favorable than in the former; the same probabilities, therefore, attach to
them as to the others I have quoted.

AFTER PETIT'S OPERATION.
79
There can be little doubt that the majority of these
fatal cases were the victims of time; that many of them
might have been relieved by the taxis at a sufficiently
early period; and that either Petit's or the operation by
opening the sac (the taxis failing) would have saved
them if time had not run on; this I am aware is an
error little imputable to the distinguished surgeons by
whom these operations were performed. It is generally
the unfortunate patient who is the cause of his own
disaster.
I have expressed my belief that in three or four of
these cases Petit's operation might have saved life; but,
on the other hand, it is not improbable that of the 42
recoveries, all might not have occurred if the sac had
not been opened; of course this is matter of conjecture.
I now proceed to examine the same records of those
operations in which the sac was not opened,
which for brevity's sake may be called Petit's,
Record of
cases when the
sac was not
although much and very advantageously opened.
modified since his time by Key, Luke, Solly, Hancock,
Gay, and other able surgeons.
The first two years give 86 cases; i. e., 55 recoveries,
31 deaths.
The third year gives 39 cases; i. e., 24 recoveries, 15
deaths. Total number in three years-126 cases, and 46
deaths.
In the first series, where the sac was opened, as the
state of the parts was shown by that pro- Sac not being
ceeding, a selection could be made of such opened, the
cases as gave presumptive proof of their contents at the
state of the

80
AMOUNT AND CAUSES OF MORTALITY
time of the
operation un-
known and can-
not be stated.
being decidedly unfavorable or otherwise
at the time of the operation; in this series
no such means were offered, from the very
fact of the sac not having been opened. I therefore
give the whole without selection, and any conclusions
which can be drawn must be deduced from autopsies
when made, or from the narrative when not made.
First Quarter.-CASE 19.-Femoral. Died with
pleuro-pneumonia, but as the symptoms are
Analysis.
not detailed, and there was no autopsy, there
is nothing certain as to the abdomen. Death on the
ninth day.
CASE 22.-Femoral. Death on the sixth day. Autopsy
showed perforation of the bowel at the seat of stricture.
CASE 23.-Femoral. Death from peritonitis third
day.
CASE 21.-Scrotal. Must I think be added to this list,
for it is stated that an opening was made into the abdo-
men, not through the ring. At the autopsy it was found
that the strangulation was not relieved. There were
7 recoveries.
Second Quarter. -CASE 15.-Femoral. Condition
favorable, peritonitis following day. Death on the third
day.
CASE 17.-Femoral. Death from peritonitis on the
third day.
CASE 21.-Femoral. Death on the second day, im-
puted chiefly to extensive hæmorrhage from an artery

AFTER PETIT'S OPERATION.
81
supposed to have been the obturatrix.
Autopsy im-
perfect. There were 5 recoveries.
Third Quarter.-CASE 25.-Femoral. Strangulation
fifteen hours. Peritonitis at the time of the operation.
Death from peritonitis ten days afterwards.
CASE 26.-Femoral. Strangulation fifteen hours.
Peritonitis at the time of the operation. Death eleven
days afterwards. There was cellular inflammation about
the wound; not stated whether there was an autopsy.
66
CASE 30. It was intended to open the sac, but an
external layer having been mistaken for it, this was not
done. Hernia returned; and at the autopsy bowel found
strangulated and nearly gangrenous." There were 2
recoveries.
Fourth Quarter.-CASE 17.-Femoral. Strangulation
four days. Death from peritonitis.
CASE 18.--Femoral. Death from peritonitis fifth
day.
CASE 27.-Femoral. Strangulation ten days. Death
from peritonitis.
CASE 28.-Scrotal. Strangulation twelve hours. Death
from peritonitis the same day.
CASE 14.-Femoral. In this case it is most probable
that it was intended to open the sac, which was not, how-
ever effected. It is stated "that a considerable mass of
fat was cut away, under the belief that it was omentum,"
(an appearance very capable, I may add, of deceiving a
6

82
CAUSES OF DEATH THESAME
good surgeon). The account, however, is not very clear.
"At the autopsy, the sac was found empty and un-
opened. It was surrounded by enlarged glands and
lobulated fat much resembling omentum." There were
10 recoveries.
The result then is, that out of 39 cases in which
the sac was not opened there were 15 deaths; of
these, no doubt, there were several in which circum-
stances beyond control produced the fatal termina-
tion, as well as in the first series, where the sac was
opened; but what the proportion may have been it is
not equally possible to judge, inasmuch as the state of
the contained parts was not seen when the operation
was performed, either in those who recovered or in those
who died.
We may now return to the supposed analogy between
Petit's operation and the Taxis, on which
show that the its advocates chiefly base its supposed
These facts
analogy
ration fails.
be-
There is another fact,
When hernia has been
tween the taxis advantages. (Its advantages in appropriate.
and Petit's ope- cases I by no means deny.) The preceding
statement justifies me in affirming that there
is no true analogy between them. Death hardly ever
occurs after a successful taxis.
sufficiently worthy of notice.
reduced by the taxis, recovery is generally immediate.
When by Petit's operation it is much otherwise. Mr.
Ward says the shortest period in which a case of un-
opened sac had recovered was the tenth day. I avail
myself of this information in comparing this with the
taxis. The inevitable conclusion is, that there are cir-

AFTER PETIT'S AND THE OLD OPERATION. 83
cumstances involved in Petit's operation which cause
the difference in the result, and these demand inquiry.
A reference to the fatal cases in the second series will
show that the immediate causes of death in
Causes of death
the same as
both operations are precisely the same, when the sac
chiefly peritonitis; also inflammation of is opened.
the lungs, especially bronchitis, erysipelas, gangrene of
external parts, pyæmia, &c.; the next point is as to the
relative numbers. How does the matter stand with
reference to Petit's and the old operation? If the
analysis of the fatal cases after the latter be in the main
allowed to be just, by subtracting the unavoidable
deaths it reduces the number to twelve out of eighty-seven
(p. 76), in which the operation itself, may (or may not)
have contributed essentially to the result. On the other
hand, we find that fifteen out of thirty-nine operations
where the sac was not opened died, and making every
allowance for cases of unavoidable death, as
in the former series (but which, the sac
not being opened, could not be justly ascer-
tained), the difference may be deemed not
very great. Furthermore, it must be con-
sidered, that Petit's operation is only performed in
selected cases, and generally at an earlier period,* and
when the sac also is opened at an early period, the
The question
would be as to
the relative pro-
portions sup-
posing all cir-
cumstances the
same.
*Mr. Ward states, that in the forty-two cases of femoral hernia, in
which the sac was unopened, the period during which the strangulation
had lasted prior to the operation was less by twenty hours than in the
cases where the sac was opened. He thinks, that if an equal number of
cases precisely similar as to duration and other circumstances, were ope-
rated on by surgeons of the same skill, there would be no difference in the
results. This may be doubted.

84
THREE STAGES IN STRANGULATED HERNIA.
amount of success is comparatively great.*
* When these
matters are duly estimated, the relative merits of the
two may be better appreciated-of this presently; but it
will, I think, be conceded, that the results in every case,
whether accomplished by the taxis, by Petit's operation,
or the old one, depend mainly on the conditions existing
What condi- prior to the operations. A few observations
on these may now be permitted. We ask the
ceed. What question, what constitutes the difference
which in certain cases allows a hernia to be
tions allow the
taxis to suc-
Petit's opera-
tion, and,
finally, what
require the sac
to be opened.
reduced without division of the ring, i. e.,
by the taxis, and in others does not?
Again, what is the cause of those cases so often ter-
minating fatally when it has been necessary to divide
the ring, albeit the sac is not opened?
The period within which a hernia is reducible varies
much according to the degree of strangulation, which
depends upon the tightness of the stricture, and the
changes in the bowel; I believe that while the latter re-
mains smooth and polished, not grooved or nipped, not
thickened materially by congestion, it may be returned,
and so much the more readily as these changes have less
advanced,† and when returned, the state of the bowel
speedily becomes normal within the abdomen. This is
the period available for the taxis. When the converse
Mr. Luke states that of 60 cases, operated on within forty-eight hours,
12 died; whilst of 38, after more than forty-eight hours, 15 died.
Mr. Gay attributes the difficulty of reduction in a great degree to the
angular or twisted position of the bowel in a hernia. That such changes
may occur, and act unfavorably in some cases, I have no doubt, but
neither in my own, nor in the much larger number I have seen under other
surgeons, have I been aware of this state existing.

INFLUENCE ON THE THREE OPERATIONS.
85
is the case, when the bowel at the ring is no longer
smooth, but nipped and grooved, and its tissues con-
gested, when also, if I am right in my conjecture, a
greater degree of active constriction has taken place in
the ring, a division is necessary to return the contents
and whether that division is made external to the sac,
or otherwise, by this time, such changes have taken place
in the bowel as render it but too capable, when replaced
in the abdomen, of increasing any peritonitis which may
have commenced, or of exciting it, if not; and hence the
number of cases of fatal peritonitis, after Petit's opera-
tion as well as the old. If the causes of the different
results of the taxis and Petit's operation are thus ex-
plained; it will further free the operation of opening
the sac, from much of the suspicion which has attached
to it. The two grounds of objection to that procedure,
are, on the one hand, the opening of the peritoneal sac,
on the other the exposure to the air, and handling the
contents. The former I believe to have been much
exaggerated; and I quite agree with Mr. Le Gros
Clark that the sac of a hernia, although a part of the
peritoneum, is generally so altered in its pathological con-
dition, as to be very differently affected by a wound
than the peritoneum proper and unchanged. The latter
cannot be denied, and is the very essence
Brief estimate
both.
of any valid objection; but on the other of the advan-
tages and dis-
hand, there are advantages often arising advantages of
from opening the sac, which must be taken
in its favour; and after all it becomes a balance between
the two, a balance, however, which can only be deduced
* The Lancet,' March 3, 1855.

86
ESTIMATE OF PETIT'S OPERATION.
from a fair estimate of both, and applied to each case
which may present itself.
ome
It must not be supposed that I have argued this
Where Petit's question with any prejudice against Petit's
operation is
applicable to operation, I only think that its true bearings
be performed. have not been sufficiently considered. I
should undoubtedly prefer it when the ring can be
divided with facility, and where there is no reason to
suppose such a state of the contents as to require exami-
nation; but when the statements now made are duly
considered, I do not think there will be found any inhe-
rent difference in the two operations so intrinsically
great, as to lead us to prefer Petit's, where these condi-
tions do not recommend it, and, indeed, his own advo-
cacy can hardly be considered to go further than
this.
The following case, to which I have alluded in the
early part of this memoir, interesting in many respects,
I give more in detail.
March 12th, 1845.-I was sent for, to the wife of
the coachman of a gentleman, who resided about fifteen
miles from Exeter, where I met three of my medical
friends in consultation. She had given birth to a child
ten days before, and was then supposed to be labouring
under strangulated umbilical hernia.
Chiefly above, but extending a little below the umbi-
licus, and rather to the right side, was a large tumour,
having no well-defined edge, and under which the
fingers could not be passed, but it was evident, from
percussion, that intestine was beneath. On steady pres-

CASE OF SUPPOSED EXOMPHALOS.
87
sure it appeared to recede, but slowly would return
when that pressure was removed. It was tender, but
not much so. She had pain in the abdomen, looked
distressed, vomited intestinal secretions, and had obsti-
nate constipation. The tongue furred and bilious.
Pulse nearly 100, and active. The umbilical ring could
be felt. The symptoms had continued four days. It
was stated, that she had rather improved since the
morning. My advice was, that in such a doubtful case,
an operation should be deferred, and it was arranged
that I should see her on the following day.
On the 13th, I saw her again with the same con-
sultants, and there having been no improvement, an
operation was determined on, (a doubt still strongly
existing in my mind as to its being an hernia), and it
was also determined to make it in the following way.
which would involve no serious consequences, if a hernia
did not exist :
I made an incision of about three inches and a half
in the line of the linea alba down to and a little below
the umbilicus, this showed nothing but the linea alba.
I cautiously divided that, and came to the peritoneum of
a natural appearance, and not tense. Here I stopped,
being myself satisfied; but after an anxious consultation,
by the desire of my consultants, I divided the linea alba
for a further space of about two inches downwards,
underneath which was peritoneum still of a perfectly
natural colour. Not having opened the cavity of the
abdomen, there was now nothing but a wound of com-
mon parts; this I closed.
On the 17th, I was informed that the symptoms were

88
CONCLUDING SUMMARY.
yielding to the use of injections thrown up by the long
tube. She subsequently recovered.
This no doubt was one of those cases, not of inter-
nal strangulation, for there most probably would have
been no recovery; but of internal inflammation similar
to those recorded by Mr. Pott, but accompanied with a
tumefaction near the umbilicus, so peculiar as to justify
the apprehension that it was hernia.
I shall now conclude by briefly stating the principal
points which it has been the object of this memoir to
bring before the notice of the profession; and first, I
shall endeavour, notwithstanding the repetition it in-
volves, to set forth those which are of general appli-
cation, as regards all hernia. Which equally con-
cern the taxis; the operation without, and that by
opening the sac, and which tend to illustrate the symp-
toms which more or less take place in each. In this
part, there are few statements which do not find support
in previous authority; the conclusions to a considerable
extent may be considered more peculiarly my own, and
as such, must be received with allowance and with
caution. They are chiefly a summary of what has been
stated pp. 35 to 37, and 82 to 86, and are as follows:
That the taxis commonly succeeds soon after strangu-
lation, but with increasing difficulty as time goes on, is

CONCLUDING SUMMARY.
89
a received fact. It succeeds, probably, before the
changes which have been made by the stricture have
made much progress, i. e., before the bowel has been
long and strongly nipped; before the tissues of the
bowel itself have been much thickened by congestion;
and it may be, before the return is further impeded by
the active constriction of the ring itself; all causes me-
chanically preventing it, and as these changes operate
more and more, so the return of the contents becomes
more and more difficult, and after a time impossible.
In this statement may also be found an explanation of
the very natural question, why patients rarely die when
the taxis succeeds; in fact, the taxis can only succeed,
when these changes have not proceeded so far as to
originate, or maintain (if already existing), any serious
amount of mischief within the cavity. The taxis suc-
ceeding, and the contents replaced, everything speedily
resumes the natural course. This may be termed the
First Period.
When these changes have gone so far as mechani-
cally to prevent the return of the hernia by the taxis,
they have also gone so far as to produce a more grave
and lasting mischief. The return of the contents can
now only be obtained by the division of the stricture,
but when this is effected, peritonitis, in a greater or less
degree, having for the most part already commenced, or,
being subsequently induced by the advanced stage of
mischief in the returned bowel, those results very com-
monly follow, which occur, though not equally, after
both operations by incision, and often to a fatal extent.
Between the time when the taxis has ceased to be

90
CONCLUDING SUMMARY.
practicable, and that when, to return the contents, an
opening of the ssac is necessary, an interval intervenes,
when Petit's operation is practicable, other circum-
stances not forbidding it, and this may be considered
the Second Period; but as regards any true analogy be-
tween that operation and the taxis, the opinion is, as it
appears to me, wholly fallacious; it goes no further than
the mechanical advantage of returning the hernia with-
out opening the sac. All other circumstances are now
different. a vote sofili com has our
When these changes have further advanced. When
adhesions have formed, or other causes prevent the sac
from being emptied of its contents, or relieved in situ by
Petit's operation if not emptied, the simple division of
the stricture will not suffice. The sac must be opened.
This is the Third Period, and it will not be wondered at,
that death more frequently occurs, because the graver
the changes, the greater the danger from collapse, peri-
tonitis, gangrene, &c. &c. These changes often extend
to the utter disorganization of the bowel.
med H
Two important questions connected with these opera-
tions remain :
elst. To what extent are the manipulations in attempt-
ing the taxis prejudicial or otherwise? Before the First
Period is over, generally highly beneficial if prudently
conducted; after it, often more or less injurious. The
difficulty is in determining when that period is past.
This can only be deduced from want of success in the
attempt in most instances: nevertheless, the conse-

CONCLUDING SUMMARY.
91
quences so commonly imputed to the taxis, are much
more frequently the result of the changes which have
been advancing in the contents of abdomen during an
unnecessary delay.
2d. To what extent do the two operations by incision
prove prejudicial per se? The wound in Petit's opera-
tion can rarely do so, excepting so far as it may give rise
to erysipelatous inflammation. The old operation has
been subjected to reproaches it does not deserve; but
still, by exposing the contents to the air, by the hand-
ling the unprotected bowels, and in many cases by
establishing a communication between a wound digesting
badly and the cavity of the abdomen, it induces risks
which often cannot be avoided; the danger, however, in
both operations, does not arise from such causes in any
proportionate degree to that from the previous changes
in the viscera concerned.
A difference of opinion exists with reference to the
effects of the incision in the sac. It is probable, that in
quite recent hernia, the state of the membrane being un-
changed, it may be a source of evil; but in old herniæ,
its constitution is so altered as to render any injurious
results very doubtful.
The attempt now made to explain the conditions
which govern the different stages of strangulated hernia,
and their bearings on the three operations, may be ac-
cepted or otherwise; but this good will at all events re-
sult from it, that if not satisfactory, it may induce others
to redeem them from the doubt, the obscurity, and con-

92
CONCLUDING SUMMARY.
trariety of opinion at present prevailing. There are some
other points which I have commented upon in this
memoir, which also may be deserving a brief re-
capitulation.
1st. That omento-intestinal herniæ are more fatal than
any other class. The reasons for this are submitted
(p. 66).
2d. That as regards the stricture or strictures ana-
logies with other phenomena, especially those which are
observed in paraphymosis, offer grounds for supposing
an active constricting power (p. 29).
3d. That the peritonitis originating from the strangu-
lation in hernia, differs in type from idiopathic; that its
symptoms are materially modified by the sympathetic
influence of the strangulated portion, and that its being
so often "latent" is owing to the processes of inflam-
mation being kept in abeyance by that influence, especi-
ally while the constriction is not freed (p. 34-37).
4th. That the intestine above the stricture, dilated as
it always is, may not unfrequently be the seat of in-
jury, if a wound is inflicted on the bowel in the
operation (p. 27).
5th. That the chronic character attributed to the
strangulation when occurring in old people, rests upon
very doubtful evidence, for hernia being incident to that
portion of existence in a very great proportion of cases,

CONCLUDING SUMMARY.
93
and consequently strangulation also, and while the larger
number of fatal cases on record are of an acute cha-
racter, it is a fair conclusion, that even in the old, such
is the predominant condition (pp. 8, 9, &c.).
6th. That in addition to the general indications
offered by the fluid, there may be these further con-
clusions afforded by it, as determined by the degree of
constriction: namely, that when the fluid can be pressed
into the abdomen, the degree is not extreme, and vice
versá; and again, where no fluid is found in the sac it
affords a probable indication of the degree of stricture
being extreme. Furthermore, when in such cases a gush
takes place from the abdomen, on the division of the
stricture, it shows much congestion or inflammation
there (p. 23).*
*
7th. That inguinal hernia in the female, although
sufficiently common, is rarely strangulated (p. 9).
between the two
8th. That in very large femoral hernia in the female,
it is sometimes impossible to make out Poupart's liga-
ment; and in these, the diagnosis may be founded on a
different principle (p. 10).
To this I may further add, that the important ques-
* Since this part of the memoir went to the press, I had occasion to
look over again the earlier volumes of the 'Medico-Chirurgical Trans-
actions,' and I found that a surgeon whose merits have hardly been appre-
ciated as they deserve, Mr. Chevalier, had made very similar remarks on
the indications offered by the fluid. They have, however, been but little
regarded.

94
CONCLUSION.
tion of the action of purgatives, as connected with the
pathological condition of the alimentary canal after the
reduction of hernia, has been considered; more, how-
ever, with the view of exonerating them from undue pre-
judice, than with the intention of recommending their
use, otherwise than by injections (p. 32). The frequent
occurrence and fatal complication of erysipelas of a bad
type, and its causes, have also been adverted to (p. 38),
and in dealing with the question of the large mortality
of these operations in rural districts, I have endeavoured
to explain the cause by reference to the distances which
operate adversely in many very intelligible ways (p. 30).*
dong
46
Time and chance happen to all men;" but in very
different proportions. To the members of my own pro-
fession the latter is abundantly the case; but as regards
the former, it must be confessed that it is in an inverse
ratio, and especially to that class who have most fre-
quently to grapple with the difficulties and great re-
sponsibilities which involve the practice in strangulated
hernia. Leisure is so scanty, that they can ill spare the
time for reading any useless or superfluous matter. So
A to bebuvot
bes
* In speaking of the operation, I have alluded (p. 17) to the difficulty
often experienced in returning the intestines into the abdomen, from the
inflated condition of the viscera within; from the tension of the muscles;
and the struggling of the patient; and have mentioned Dr. Buchanan's
having proposed a plan to meet this, a plan, however, which so much de-
pends upon the control the patient can exert over himself as to make it
often difficult. I have, however, omitted to speak of another method
which I have sometimes tried with much success. It is simply to turn
the patient on the opposite side. It converts enemies into friends-for the
bowels within no longer resist the ingress of those protruded, but rather
draw them back.

CONCLUSION.
95
deeply impressed am I with the paramount importance
of this being a maxim to be attended to by every one
who ventures to publish, that I have endeavoured to
make this memoir as brief as I possibly could, con-
sistently with the importance of the subject. It too
oftens happens that Horace's warning applies in such
but it is possible to reverse it. The public will
always look with a favorable eye on the attempt, to be
brief without obscurity.
cases,
J. E. ADLARD, PRINTER, BARTHOLOMEW CLOSE..


London, New Burlington Street,
January, 1859.
MR. CHURCHILL'S
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AND
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EDICINA
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in

A CLASSIFIED INDEX
TO
MR. CHURCHILL'S CATALOGUE.
Odontological Soc. Transactions 21
ANATOMY.
DENTISTRY.
PAGE
PAGE
Anatomical Remembrancer
Beale on Liver ..
5
3 Blundell's Painless Extraction. 7
Clark's Odontalgist ..
9
Hassall's Micros. Anatomy
14
Holden's Human Osteology
logical Anatomy
Maclise's Surgical Anatomy
Paget's Catalogue
Sibson's Medical Anatomy
Toynbee's Catalogue..
Wheeler's Handbook..
Wilson's Anatomy
Gray on the Teeth
13
15
Jones' and Sieveking's Patho-
17
19
21
wwwwwww
..
⌁www
DISEASES of the URINARY
25 and GENERATIVE ORGANS,
and SYPHILIS.
28
30
31 Acton on Reproductive Organs
Coote on Syphilis
377
Coulson on Bladder
Do. on Lithotomy
Egan on Syphilis
..
3
MATERIA MEDICA and
PHARMACY.
Bateman's Magnacopia
Beasley's Formulary..
Do.
Receipt Book
PAGE
4
5
5
Do. Book of Prescriptions 5
Lane's Materia Medica
Pereira's Selecta e Præscriptis
Pharmacopoeia Londinensis
Prescriber's Pharmacopoeia
Royle's Materia Medica
Spurgin's Materia Medica..
9 Squire's Pharmacopoeia
10 Steggall's Materia Medica
18
22
22
22
24
26
26
26
10 Do. First Lines for Chemists 26
11 Stowe's Toxicological Chart .. 26
17 Taylor on Poisons
20 Wittstein's Pharmacy
..
27
.. 30
• >、• ལེས
CHEMISTRY.
Abel & Bloxam's Handbook
..
Bowman's Practical Chemistry
Do.
Medical
Chalmers' Electro-Chemistry..
Fownes' Manual of Chemistry.. 12
Judd on Syphilis
Milton on Gonorrhoea
do.
7
Parker on Syphilis
21
8
Todd on Urinary Organs.
..
Wilson on Syphilis
28
31
mm⌁
Do.
Actonian Prize ..
12
Do.
Qualitative Analysis
12
Do.
Chemical Tables..
12
DISEASES OF WOMEN
Do.
Fresenius' Chemical Analysis.. 12
Galloway's First Step
Do. Analysis..
Diagrams
Griffiths' Four Seasons
Horsley's Chem. Philosophy
Jones.-Mulder on Wine..
Odling's Practical Chemistry
Plattner on Blowpipe
Speer's Pathol. Chemistry
AND CHILDREN.
MEDICINE.
Adams on Rheumatic Gout
Addison on Supra-Renal Capsules 4
Addison on Cells
12
..
Bennet on Uterus
5
Alexander on Rheumatism
3433
12
Do. on Uterine Pathology..
5
Barclay on Diagnosis
5
12
Bird on Children
6 Barlow's Practice of Medicine
4
13
Brown on Women
7 Basham on Dropsy
5
16
..
Do. on Scarlatina..
7 Beale on Urine..
5
17 Eyre's Practical Remarks
11
Billing's First Principles
..
21
Hood on Crowing
16
Bird's Urinary Deposits
..
..
22
Lee's Ovarian & Uterine Diseases
18
Bird on Charcoal
..
25
Lee on Diseases of Uterus
18
Brinton on Ulcer
..
Do. on Speculum
18
Budd on the Liver
..
wwwwww
Roberton on Women..
24
Do. on Stomach
6777
..
CHOLERA.
Acland on Cholera at Oxford ..
Baly and Gull-Reports
Snow on Cholera
Rowe on Females
..
Smith on Leucorrhoea
24 Camplin on Diabetes..
25 Chambers on Digestion
8
8
3
Tilt on Diseases of Women
..
27 Davey's Ganglionic
10
..
4
Do. on Change of Life
27 Eyre on Stomach
11
25
Underwood on Children
28
Fuller on Rheumatism
12
West on Women
29
Gairdner on Gout
12
..
Granville on Sudden Death
13
..
wwwww
www
Gully's Simple Treatment
13
CLIMATE.
Francis on Change of Climate.. 12
Habershon on Stomach
13
HYGIENE.
..
Hall on Apnoea ..
14
Armstrong on Naval Hygiene
3
Hall's Observations
14
..
Hall on Torquay..
Haviland on Climate..
Lee on Climate ..
14
Beale's Laws of Health
4
Harrison on Lead in Water
14
..
14
Do. Health and Diseases
4
Hassall on Urine
14
..
66
..
16
26
Martin on the Undercliff
Martin (J. R.) on Tropical
DEFORMITIES, &c.
Bigg on Deformities ..
Bishop on Deformities
Do. Articulate Sounds
Brodhurst on Spine ..
on Clubfoot
Do.
Hare on Spine
Hugman on Hip Joint
Inman on Spine..
Tamplin on Spine
..
18 Bennet on Nutrition ..
19 Blundell's Medicina Mechanica
20 Carter on Training
Cornaro on Long Life
Hartwig on Sea Bathing
Do.
Hufeland's Art
Physical Education 14
Lee's Watering Places of England 18
Do.
do. Germany,
France, and Switzerland
6 Lee's Rhenish Watering Places 18
7 Robertson on Diet
14 Rumsey's State Medicine
16 Van Oven's Decline of Life
5 Headland on Medicines
15
..
7 Hooper's Medical Dictionary
16
..
8
Hooper's Physician's
Vade-
9
Mecum
13
14
Jones' Animal Chemistry
17
Lugol on Scrofula
19
16
Peacock on Influenza
21
Do. on Heart
21
Pym on Yellow Fever
22
18
Roberts on Palsy
24
..
Robertson on Gout
23
..
7 Pickford on Hygiene
..
22
Savory's Compendium
24
23
Semple on Cough
24
..
..
24 Shaw's Remembrancer
25
..
29 Steggall's Medical Manual
26
Wilson on Healthy Skin ..
Do. on Mineral Waters
31
Do. Gregory's Conspectus 26
31
Do. Celsus..
26
3G

CLASSIFIED INDEX.
MEDICINE-continued.
Thomas' Practice of Physic
Thudichum on Urine
Wegg's Observations..
PAGE
OPHTHALMOLOGY.
27 Cooper on Near Sight
27 Dalrymple on Eye..
29 Dixon on the Eye
30
19
30
Hogg on Ophthalmoscope
Holthouse on Strabismus..
..
Wells on Gout ..
What to Observe
Whitehead on Transmission
Williams' Principles..
30
Wright on Headaches
.. 30
Jago on Ocular Spectres
MICROSCOPE.
Beale on Microscope in Medicine
Do.
How to Work
do.
Carpenter on Microscope..
Do. on Impaired Vision
Jacob on Eye-ball
Jones' Ophthalmic Medicine
Do. Defects of Sight
Do. Eye and Ear
PAGE
SCIENCE.
PAGE
9 Bird's Natural Philosophy. 6
10 Burnett's Philosophy of Spirits 8
15 Hinds' Harmonies
15 Jones on Vision ..
..
..
11 Garner's Eutherapeia
13
..
15 Hardwich's Photography.
14
15
17
16
..
16
Do. on Body, Sense, and Mind 17
Mayne's Lexicon
19
.. 17
Price's Photographic Manipula-
17
..
tion ...
22
17
Nourse's Students' Tables
21
Rainey on Shells
23
21
Reymond's Animal Electricity 23
29
Taylor's Medical Jurisprudence 27
Vestiges of Creation ..
28
Sequel to ditto
28
Unger's Botanical Letters
28
..
Nunneley on the Organs of Vi-
5
sion
..
5
Walton on Ophthalmic
8
www
.. 24
Schacht on
MISCELLANEOUS.
Acton on Prostitution
Atkinson's Bibliography
Bascome on Epidemics
Bryce on Sebastopol ..
Cooley's Cyclopædia ..
..
PHYSIOLOGY.
Carpenter's Human..
Do. Comparative
Do. Manual ..
Cottle's Human ..
3 Hilton on the Cranium
4 Richardson on Coagulation
4
..
8
9
11
Forbes' Nature and Art in Disease 12
Davy's (Sir H.) Remains
Gully on Water Cure..
mmm
PSYCHOLOGY.
..
10
..
15
23
888058
Bucknill and Tuke's Psycholo-
gical Medicine
..
13
Burgess on Madness..
13
Burnett on Insanity
..
15
Conolly on Asylums
..
mmm
..
..
20
21
8
8
16
19
Guy's Hospital Reports
Haycock's Veterinary
Lane's Hydropathy
Marcet on Food ..
Massy on Recruits
Part's Case Book
..
Pettigrew on Superstitions
18 Davey on Nature of Insanity
19 Dunn's Physiological Psycho-
logy ..
..
28
Hood on Criminal Lunatics 16
22 Jacobi on Hospitals, by Tuke..
Knaggs on Criminal Lunatics..
Millingen on Treatment of In-
NERVOUS DISEASES AND
INDIGESTION.
Anderson on Nervous Affections
Carter on Hysteria
Child on Indigestion
Downing on Neuralgia
Hunt on Heartburn
Lobb on Nervous Affections
sane
Monro on Insanity
Do. Private Asylums
Noble on Psychology
Do. on Mind ..
4 Williams (J.) on Insanity
..
Fergusson's Surgery...
779
SURGERY.
Ashton on Rectum
Bellingham on Aneurism..
Bigg on Artificial Limbs..
Bishop on Bones..
Chapman on Ulcers
Do. Varicose Veins
Cooper (Sir A.) on Testis
..
46660
9
9
..
10
9
Cooper's (B.) Surgery
9
10
Do. (S.) Surg. Dictionary
9
Curling on Rectum
10
11
..
Do. on Testis
10
..
Druitt's Surgery
11
..
11
17
Harrison on Stricture
13
20
**
Higginbottom on Nitrate of Silver 15
Hodgson on Prostate..
15
..
20
Jordan's Clinical Surgery
17
..
20 Laurence on Cancer ..
18
..
..
20
Lawrence on Ruptures
18
..
20
Lee on Hæmorrhoids
18
30
Liston's Surgery..
18
Williams (J. H) Unsoundness of
Mind..
Macleod's Surgery of the Crimea 19
..
Radcliffe on Epilepsy
23
Reynolds on the Brain
23
..
..
Rowe on Nervous Diseases
24
..
Sieveking on Epilepsy
Todd on Nervous System..
Turnbull on Stomach
25
11 Winslow's Lettsomian
Do. Law of Lunacy
PULMONARY and CHEST
DISEASES, &c.
Pemberton on Melanosis
Pirrie on Surgery
Smith on Stricture
Snow on Chloroform..
30
Maclise on Fractures..
19
..
..
31
Nottingham on the Ear
20
..
31
..
Nunneley on Erysipelas
21
22
22
..
**
25
25
28
..
Addison on Healthy and Dis-
eased Structure
Steggall's Surgical Manual
26
28
3
Teale on Amputation
27
..
Billing on Lungs and Heart
6
Thompson on Stricture
27
..
..
Blakiston on the Chest
6
..
Do. on Prostate
27
..
wwwwww
Bright on the Chest..
7
Wade on Stricture
..
29
Do.
OBSTETRICS.
Barnes on Placenta Prævia
Davis on Parturition..
Johnston & Sinclair's Midwifery 17
Lee's Clinical Midwifery
Pretty's Aids during Labour
Ramsbotham's Obstetrics..
Smellie's Obstetric Plates..
Smith's Manual of Obstetrics
Swayne's Aphorisms..
Waller's Midwifery
Cotton on Consumption
10
..
Watson on the Larynx
29
..
Do. on Stethoscope
10 Wilson on the Skin
31
4
11
Davies on Lungs and Heart
Dobell on the Chest ..
Fenwick on Consumption..
10
..
Do. Portraits of Skin Diseases 31
11
Yearsley on Deafness
..
11
Do. on Throat
31
31
18
Laennec on Auscultation
17
23
..
Madden on Consumption.
23 Markham on Heart
19
20
..
Midwifery..
..
..
29 Weber on Auscultation
23 Richardson on Consumption
25 Skoda on Auscultation
25 Thompson on Consumption
26 Wardrop on the Heart
23
..
20
27
29
**
29
**

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