PRACTICAL OBSERVATIONS ON STRANGULATED HERNIA,

315 doctrine of the general unity of design," are capable of almost universal application, and I shall adventure, probably, some future observations in elucidation of the same. In the crude and state that they are here put forth, they must be received with that liberal indulgence which men of true science well know must be allowed in the discussion of subjects which have hitherto eluded all research, and are yet involved in the darkest shades of uncertainty and doubt. An analysis of the treatment of gout will form the subject of another paper. February, 1845.

undeveloped

PRACTICAL OBSERVATIONS ON STRANGULATED

HERNIA, WITH REMARKS ON THE CAUSES OF THE FATALITY IN THAT COMPLAINT, SO FAR AS RESULTS FROM IMPROPER TREATMENT. WITH A BRIEF SUMMARY OF THE AUTHOR’S PRACTICE.

bowel is merely congested, evacuations will usually occur within the first twenty-four hours, but in no case whatever should purgatives be administered until the day after the operation at the very least, and seldom so soon. If, at length, you determine to solicit the bowels, begin by an injection of’ warm water. There is no necessity for the too common anxiety about the action of the bowels. If, however, the injection shall not have directly obtained any discharges, nor indirectly, by exciting the natural efforts, about the second or even third day, you may consider the question of aperients; then employ them only in small doses, in very mild forms, and repeated at longer or shorter intervals, so that they produce no disturbance. If they produce hiccup, nausea, or irritability of stomach, provided that they are not such kinds as ordinarily produce this effect, as jalap, for example; do not be trying to combine them so as to allay the irritability of the organ, but take the hint nature is offering, and instantly relinquish

their

use.

An evacuation without medicine is a very acceptable occurrence, but you can by no means place the same favourable conBy GEORGE MACILWAIN, Esq. Surgeon. struction on one artificially procured. In protracted costiveness Formerly Surgeon to the City of London Truss Society, Consulting the bowels are sometimes torpid from sluggishness in the liver, Surgeon to the Finsbury Dispensary, &c. when the best aperient is a grain or two of calomel with two (Concluded from page 286.) grains of confection of opium. FROM the preceding observations it will be easy to predict the If you treat a patient in this manner you will seldom have any and I can assert, further, that if there were peritonitis practice I recommend and pursue. peritonitis; When sent for to a case of strangulated hernia, if I make up my previously to the operation, it will probably subside; a fact mind that the hernia is reducible, I apply the taxis at once; if I observed, also, by other practical surgeons. determine otherwise, the tobacco is previously administered. If If, however, the peritonitis require active interference, the many persons are in the room, they are requested to retire ; they question is, should the patient be bled?* In many cases, certainly only disturb the patient; for the same reason, pupils in an hos- not; in some, bleeding would be serviceable. If, as is frequently pital should not be allowed to crowd round a patient’s bed: there the case, the patient had been treated previously to the operation is nothing to be learnt by it, but much that may foil you, by the by some other surgeon, and largely bled, I would not repeat it; alarm and excitement it occasions. It is desirable that the sur- and in some other cases, where no bleeding had been employed, I geon should superintend the administration of the tobacco, and should be extremely circumspect and cautious in employing it; cases immediately on the production of lassitude, (if the hernia do not wherein the duration of the complaint, questionable treatment, or retire, which sometimes happens,) proceed to endeavour to reduce other causes, have been followed by great depression. In many such it. If he cannot accomplish this, he should allow his patient instances, the excitement of the pulse masks the case, and obscures fairly to recover from the effects of the tobacco, and at once pro- the debility, the real source of danger. Here powerful derivatives ceed to the operation. The removal of the patient to another are the best remedies, as hot bottles to the feet, mustard poultices apartment, or to an operating theatre, is objectionable ; in fact, all to the abdomen, applied for short periods, and frequently repeated, unnecessary motion should be avoided. The discussion of the and turpentine fomentations. Actual counter-irritants are doubtful; operation is unnecessary ; there is seldom any failure in that.*>I< they are too depressing. Nevertheless, it is a question of power, To the young operator I would say, let your external incision be and where that is not deficient, a good blister has been occafree enough, and full as high up as you think you may have sionally serviceable. This will save you a good deal of to divide the stricture. Now if, on the other hand, the patient is strong, if he had not trouble, and, in the first operation or two, some anxiety also. been bled before the operation, and especially if his history or Accustom yourself, also, to use a common well-made bistoury; appearance suggested either general plethora, or his habits a fulhernia bistouries, with limited edges, &c., will probably only ness of the portal system, I would bleed him. This I would do embarrass you. Take- care always to examine the stricture once, rapidly and freely, according to his powers; but unless it before you attempt to divide it, and carry your bistoury down produced a decided remission of symptoms, I would by no means to the end, and flat on, as it were, in a depression of your fore- repeat it; nor should I be in these cases disposed to bleed a second finger. time, when the first bleeding had been full and rapidly effected, In all your manipulations be extremely gentle, and when you for reasons which I have elsewhere fully explained. Emulging have reduced the intestine, and put your patient to bed, the thing the liver, and determining to the surface of the body, are almost is the most absolute repose. In some cases, where there always desiderata in membranous inflammation. Many medicines is unusual exhaustion, a tablespoonful of gruel, and even a mouth- will effect this, but none so certainly, or so quickly rather, as ful of wine, may be allowed. In general, this is quite unnecessary, calomel and opium. In general, however, the quantity of opium the best cordial being a dose of hope and cheerfulness, which few is unnecessarily great, all that is required being, that the bowels ought to know how to administer better than a good surgeon. I be not affected, or if so, that they are affected by the bile, and can tell you that many a patient will soon fall asleep; and I need I believe that where cases have been prenot by the calomel. scarcely say, let nothing in that case induce you to disturb him, viously treated properly, all this will very rarely be necessary. which I should not mention had I not seen a surgeon go up to a In the treatment after all operations, there is something in patient that had been operated on for strangulated hernia, with a practical tact which it is difficult in writing to convey; and aldozen pupils with him, and wake the patient out of a sound sleep; though there are many special cases which I propose at some I may add, too, that that patient died. other time to make the subject of another communication, yet For the first day or two it is of great consequence to put as there is one point so important in connexion with the result of little of anything into the stomach as possible, but above all operations, that I am unwilling to pass it unmentioned-I mean things, do not administer purgative medicine. If your patient the circumstances under which stimulants are necessary or vinseem to require it, a little beef-tea or gruel may be allowed, but dicable. the less at a time the better. Ordinarily, on the performance of the operation, the symptoms There is seldom any necessity for administering purgative subside ; this, however, is not invariable. If, however, the medicine, as a part of the treatment of the operation; the time at simple suggestions which I have ventured to submit have been which it becomes admissible is different in different cases, and observed, I would guard the practitioner from hastily prescribing depends on the duration of the strangulation, the tightness of the anything except absolute repose. In other cases, the general relief may have been sufficiently stricture; in fact, on the state of the intestine. The bowels will act of themselves quite as soon after the operation as it marked and satisfactory, but there is an anomalous conis good that they should do; but in cases where the bowel is in a dition, characterized by a sort of fidgetty excitement, which is very bad condition, such as seems threatening mortification, this occasionally judiciously met by a single mild dose of calomel will be occasionally two or three days, or even more. If the * I cannot help at once impressing distrust on too liberal depletion. I * I perfectly agree, as to the abstract safety of the operation, with Mr. have seen it carried to the utmost extent, without in the least degree inin the and I have no fears of the so the Pott, participation opening peritoneum fluencing peritonitis, as examination discovered;yet the very next case much insisted on ; but I recollect when I was nearly as singular in regard to was treated in the same manner. Such men appear to me to be beyond inthe division of tendons. All the discussion about returning a hernia with. struction. The good they do may be guessed at; I know not how the harm out opening the sac is, in my view, unnecessary. can be calculated,

required

generally

316

opium. Lastly, there are conditions suggesting the administration of cordials and stimulants. In general, these remedies are not only unnecessary, but inadmissible. In special cases, I am satisfied that many a life would be saved by a prompt and judicious administration of them. I shall endeavour to realize one or two of the conditions requiring these remedies. The first is that of unusual exhaustion after the operation, seldom in young subjects requiring any interference, but in the advanced or old, rendering the administration of a slight cordial judicious. A little wine and water, with or without a very few drops of laudanum, according to circumstances, is the best form, and a single dose is in general all that this sort of position requires. The second condition seldom occurs immediately after the operation. It is a state of restlessness ; there is no pain, no complaint, no obstruction, no peritonitis, but the patient is wakeful ; he does not sleep; his pulse is small and frequent; he may be thirsty; his tongue may be moist at the edges, but without being dry; there is a paucity of secretion in the centre. Want of power is here the mischief, but be prompt, and moderate stimulants will probably turn the balance in his favour. If he is caught at the commencement of this state, a very moderate use of cordials will do wonders; if much time be lost, the case will probably be a failure. The third state is merely an exaggerated form of the preceding. His mouth may be a little dryer, but there is more restlessness, more excitement; he is complaining, apparently without any reason; he is impatient of restriction; he may make an attempt to get out of bed, yet he has no bad symptom, ordinarily so called, but he is dying. This, I think, happens chiefly in old people, and a prompt administration of wine, or other stimulant, is the and

which we can hope to save the patient. i Diarrhcea is also one of the accompaniments to strangulated ’, hernia requiring special treatment, sometimes including cordials, another objection to that view which would so pertinaciously restrict the danger to the absence of evacuations. I will now conclude by a case or two, in illustration of my own practice, premising only, that when the strangulation has existed for any time, or is accompanied by any severity of symptoms, I seldom do more than fairly try the taxis, and this failing, perform the operation. The foregoing observations are intended to represent all that is necessary in the general class of cases. I may in another communication probably discuss those of a more rare and special character. The following case occurred many years ago, when I was in the habit of adopting the treatment more or less commonly employed. The reader will form his own conclusions as to the influence which the purgatives had in producing the peritonitis. At that time the aperient I employed was either four grains of jalap, or about one drachm of sulphate of magnesia, in mint water, every four hours, until it operated. A man, aged forty-three, laboured under constipation, nausea, hiccough, great inclination to vomit, and a circumscribed pain, referred to the inguinal ring, which symptoms had arisen almost immediately on the descent of an inguinal hernia, which could not be returned. I saw him in this state on the morning of January 5th, 1822. He was ordered aperients, ice to the part, and, subsequently, an enema of tobacco infusion; but, in the evening, the symptoms were rather exacerbated than otherwise, and the taxis still failing, the operation was performed about six o’clock. The hernia was an entero-epiplocele, the intestine was highly congested, but sound ; the structure having been divided, and a portion of the omentum removed, the hernia was reduced. On being placed comfortably in bed, he felt entirely relieved from all his symptoms, the pain at the ring inclusive. He was directed to take some aperient medicine in about two hours, and to repeat it every four hours until the bowels were relieved. The next morning, the bowels had been relieved twice during the night, but he was very ill; he had had no sleep, his tongue was dry, pulse 120, and a good deal of pain, tenderness, and some tension of the abdomen. He was bled to twenty ounces, twenty-four leeches were ordered to the abdomen, to be followed by a blister, the aperient to be continued. Next day, being no better, he was again bled, but became very faint when twelve ounces had been drawn. The bleeding was discontinued, and twelve leeches applied to the abdomen. The following morning (Saturday) he was somewhat better, he had discontinued his aperient; pulse about 110 ; peritonitic symptoms somewhat less severe, but tongue very dry, and he is excessively thirsty. Ordered to take nothing but small quantities of imperial to assuage thirst. On Sunday is greatly improved, has had some good sleep, is altogether better. Towards evening he expressed a desire for food, when a small quantity of gruel was allowed. He now proceeded

only means by

to

convalescence, but had

a

very slow and tedious recovery, it

being full six weeks before the wound had firmly healed. The following case, which occurred about sixteen years ago, exemplifies a growing distrust of purgative medicine. A medical gentleman requested me to visit a female, aged sixty-six, labouring under strangulated hernia, with nausea, constipation, and

vomiting. The symptoms had continued, I understood, about fifty-six hours, during which, aperients, ice, and the tobacco enema, had been applied. Succeeding no better with the taxis

than the gentleman who had preceded me, I proceeded to lay open the sac of a large inguinal hernia, tightly strangulated. Having returned the part, and secured the wound by a few sutures, the patient was placed in bed, and directed to remain quiet for a few hours, when she would be visited again. In the morning I saw her; I found, that after waiting about four hours, my medical friend had administered a very mild aperient, and that the bowels had been relieved. She was ordered to discontinue taking any medicine, and to keep quiet. Nothing further occurred. I was, however, afraid that she would suffer from her incaution, for I found her walking about the room, dressed, within a week from the operation. The case, however, did perfectly well. On Wednesday, the 10th of February, 1836, I was desired to visit a female, aged 43, who laboured under severe symptoms of strangulated hernia. The hernia had been strangulated five days, and as the usual symptoms were coupled with tenderness, and some tension of the abdomen, I operated at once, and exposed a very small strangulated femoral hernia, very tightly strangulated, presenting some peculiarities which I will presently mention. The being concluded, and the patient placed in bed, she was desired to take nothing but a very small quantity of gruel if she desired it. On visiting her the next day, it was found that the bowels had acted once during the night, and once in the morning. All her symptoms had left her, and she felt very comfortable; the pulse, however, was rather frequent, and a little irritable. Ordered minute doses of sulphate of magnesia and mint water every eight hours. Feb. 12.-Not quite so well; some little pain in the abdomen; bowels open: as the pain is considered to be produced by the medicine, it is ordered to be discontinued. 13th.-Pain in the abdomen has subsided, she is in all respects doing well ; she had a rapid recovery. The peculiarity above alluded to was, that the tumour was composed chiefly of a much-thickened fascia propria, the sac having been produced into a sort of distinct bag with a narrow aperture, inferiorly, beneath which, very deep, lay the strangulated bowel. The hernia had, as is common, risen above Poupart’s ligament, though not in a direction towards the inguinal ring, but contrarily towards the crista of the ilium. I have not the least doubt that she had been accustomed to wear her truss with the hernia imperfectly reduced, and that thus, whilst the intestine, from its small size, escaped pressure, the sac was gradually elongated, and compressed, between the pad of the truss and Poupart’s liga-

operation

ment.

years of age, laboured under nausea, anything in the stomach, and pain and tenderness in a femoral hernia. The tumour, she said, had existed for seven years, but she had never worn a truss. I saw her on Sunday, in March, 1838, and found that she had suffered from the symptoms above stated since the previous Tuesday. The abdomen is very tender; pulse 90, and small; countenance anxious; strength a good deal exhausted; tongue dry, but not furred; says she is in less pain than she has been. Being afraid to delay, I endeavoured to compose her mind, and having fairly tried the taxis in vain, proceeded at once to the operation. I had to divide an enormous quantity of fat, which, of course, greatly increased the depth of the wound. I never saw parts so matted and agglutinated together. At length, however, I arrived at what I believed to be the sac, and found a very dense piece of omentum closely adherent to the sac, and separable only by dissection. Having detached some of the adhesions, I thought it better carefully to dissect through the omentum, which enabled me to expose a piece of strangulated bowel, adherent, indeed, to the omentum, but so recently as to be easily separated without, any violence. Proceeding with that care which an unusually deep wound rendered necessary, I at length succeeded in dividing the stricture, and replacing the bowel. The omentum, which was closely adherent throughout to the sac, and the separation of which would have involved a very unnecessary and tedious dissection, was left, and the wound closed in the usual manner. The patient was placed in bed, and-no medicine of any kind was given. In a few hours the bowels acted moderately, and subsequently, more copiously, without any assistance. In fact, the treatment consisted in keeping the patient quiet, and giving her only very small quantities of tea and gruel, until all her sympA

female,

about

sixty

constipation, inability

to retain

317 toms had subsided.

She recovered rapidly, without any check whatever. The operation was tedious. I have seldom been engaged in a more difficult or anxious dissection. I was requested by Mr. Shillito, of Putney, to see a female labouring under strangulated hernia. Mr. Shillito had seen her about an hour before, for the first time, when he learned that she had been labouring under symptoms of acute peritonitis for three days previously. On examination, the hernia (a femoral) was rather large, somewhat tense and tender; the abdomen very tender, enormously swollen, and tympanitic;

ON THE ADMINISTRATION OF INTOXICATING DOSES OF ALCOHOL IN TRAUMATIC TETANUS. By J. W. STAPLETON, Trowbridge. C]ERA’RLES Pafarmer’s labourer, aged seventeen, sustained the 24th Dec. last, a lacerated wound of the palmar surface, and outer edge of the carpus of the right hand. It was inflicted by a chaff-cutting machine, the blade of which had stripped off a flap of the integument, leaving an irregular contused edge; no on

anxious; tongue furred, but not dry; hiccough, tendinous, muscular, or nervous structures were involved, nor eructation, sickness, and occasionally vomiting. The patient was the palmar fascia exposed. Those portions of the flap appeared very weak. As it was quite evident that not a moment whose texture was destroyed were at once removed by the knife, was to be lost, I gently manipulated the hernia, convinced myself and the rest was replaced and supported with adhesive straps, that it was irreducible, and operated immediately. On opening and a light bandage covered with the cold-water dressing. On the sac, I exposed a considerable piece of omentum, in a very the sixth day, parts had nearly united, and a healthy granulating dark condition, underneath which lay a moderately large surface presented where there had been loss of substance. On knuckle of intestine, of so black a colour, that I had the afternoon of the twelfth day, (having been dressed in the mornconsiderable doubts as to the propriety of replacing it in the ing,) he came back to my surgery, complaining of intense pain, abdomen. After a little hesitation, however, I proceeded to extending from the lower extremity of the sternum, backwards, to divide the stricture, and, with great gentleness, to replace the the spine. On stripping him, I found the sternum and lower bowel. The bowel appeared to be adherent to the opposing sur- ribs powerfully retracted by tonic spasm of the diaphragm, and face within the abdomen, and this connexion I took care not to much tension of the muscles of the neck and jaw. The opisthodisturb, since, should the bowel slough, it would be an indis- tonus, which was permanent, was at times increased by violent pensable security against the effusion of fsecal matter into the clonic spasms of the same muscles; when these subsided, the arched abdomen. The omentum was, in great part, firmly adherent; form of the neck remained unaffected by their remission. The the larger portion of it was removed, the wound closed wound was bathed in an offensive sanious discharge, and had by a couple of sutures, and the patient placed in bed. I become extremely painful. As a first and obvious duty, I removed from the wound every requested that no medicine might be administered unless she became restless, when a single dose of calomel and opium might be source of pressure and irritation, applying a simple poultice, and given. On visiting her the next morning, I found that the had the patient put to bed. Three drops of croton oil were bowels had acted about two or three hours after the operation; placed upon the tongue, and a blister laid along the whole there is still nausea, hiccough, occasional threatenings of, but no course of the spinal column; and as soon as the bowels had actual, vomiting; the tongue is dry, which I attribute to her acted, a grain of the acetate of morphia was given, and repeated having taken a pill of calomel and opium. The operation was every hour. In three hours I visited him again. All the symptoms were performed on Friday evening, and it was the following Thursday. before the peritonitic symptoms had subsided. The treatment increased; there as a deep hollow at the scrobiculus cordis, and was very simple. Finding her, at the time of the operation, excruciating pain throughout the diaphragmatic region. The with turpentine fomentations, these were for a day or two con- muscles of the neck were perfectly rigid, and those of the dorsal tinued. She took no purgative medicine until the Monday, and lumbar regions participating in the tetanic spasm, all the eountenance

when the stomach appearing to be tranquil, she had some each containing four grains of jalap, which she was directed to take after intervals of four hours, provided they produced no disturbance of stomach. The first powder, however, producing uncomfortable sensations, she discontinuetl them, when she soon again became comfortable. The next day, in the evening, half an ounce of castor oil acted very comfortably. The She was allowed to take beefcase now went on favourably. tea and sopped bread; and this was gradually replaced by boiled mutton and an ordinarily plain diet. The only check was a slight attack of diarrhoea, apparently consequent on her having eaten some boiled rabbit before she was allowed to do so. As I am compressing these cases into a mere abstract, I know not if I may have said enough to convey the desperate nature of this case. I have never seen any other such recover. I have been called to two very like it: in the one case the patient was dead before I arrived; in the other, the patient sunk about an hour after the operation, the bowel having already sloughed. The nearest case of recovery which I recollect, is one of Pelletan’s, in which there were no purgatives, but injections. The few cases which I have selected from different periods of my experience, will be sufficient to exemplify the practice I recommend, and to shew that I have adopted it only by degrees, and from the growing conviction of slowly progressing experience. There must always be some fatal cases of an operation so often performed under inauspicious circumstances, which we have had no power of controlling; but, at the same time, I am satisfied, that an incalculable number of lives will be saved by any one who will simply regard the ligature or the bowel as the cause of the malady, and who will restrict his treatmentwhether before the operation or afterwards-as closely as possible to such measures as have a speedy and direct tendency to liberate the bowel: and especially if he will avoid unnecessary delay, coarse, zznskilful, or repeuted taxis, bleeding, and purgatives. The pernicious tendency of purgatives is sometimes not apparent, because cases occur in which the strangulation being either not tight, or being very recent, the bowel recovers immediately on its liberation, and, in such a case, purgatives might, no doubt, be given at once with impunity. It should be borne in mind, also, that many cases of irreducible herniae are frequently convertible into, and then treated as, strangulated. There are, however, cases-of an entirely different class, which I hope to describe fully in some future communication.

powders,

of the trunk of the body seemed anchylozed, so that when removed from the bed, he lay in the arms of those who carried him like a marble statue. He still referred all his pain to the diaphragm, and to the course of the recti. The abdomen was forcibly thrust forward, and was immovable during the respiratory act, which was maintained wholly by the thoracic muscles. No complaint was made of the hand from this time. Morphia was again given and continued throughout the night, without any mitigation of the symptoms. On the following morning, the disease was evidently proceeding with rapidity to a fatal issue. The pulse was eighty-five, labouring and constricted; the heart’s action tumultuous and irregular ; the skin of the natural temperature, and the intellect unimpaired. I gave the following injection.-Oil of turpentine, one oz.; tincture of opium, two drachms; assafcetida mixture, twelve oz. ;; hop water, eight oz. ; mix them for an injection. At the same time, two grains of morphia were sprinkled upon the surface of the blister, and the following medicines directed to be given every alternate hour-Take assafoetida, eight grains; Camphor, six grains; let them be made into a bolus to be taken immediately, and repeated every two hours ; and with these take acetate of morphia, one grain ; extract of belladonna, one grain ; extract of conium, four grains; made into a pill to be taken one hour after the bolus, and repeated every two hours. Four hours after this he was evidently worse. Blisters were now placed on the abdomen, over the recti muscles ; and as the injection was retained, I gave him three drops of croton, which soon acted copiously, yet without any remission of the symp-

joints

toms.

A fair trial of the

and antispasmodics had now been been fruitlessly occupied in their administration. The progress of the case had been uninterrupted from bad to worse. The patient lay immovably fixed, his weight resting on the back of the head and the sacrum ; the trunk of his body between these two points forming an arch, whose concavity was towards the mattrass, and within which a child might have crept without touching him. He could not open his mouth further than to allow a pill to be dropped within the teeth ; deglutition was difficult, and the lips were distorted into a horrible sardonic grin; his eyes glared from their sockets, and every, feature was indicative of the extremity of anxiety and suffering. He was perfectly sensible, and would reply to questions, but always as briefly as he could, and begging to be left alone. Pulse 90, sharp and jerking ; skm hot and dry; cheeks flushed. I make.

opiates

given; twenty-six hours having