STRANGULATED HERNIA REDUCED " EN MASSE." WITH REMARKS.

178 times

a day, with the bicarbonate of potassium and camphor mixSTRANGULATED HERNIA REDUCED " EN MASSE." ture, keeping the bowels regular by blue pill and rhubarb, with WITH REMARKS. diet. After a and nutritious a short aromatics, enjoining light, to in her and she to ROBERT WADE, Esq. Senior Surgeon to the Westminster time, general hea1th, gain began improve By General Dispensary. flesh. The dose of the iodide of potassium was increased to four, five, six, gradually up to 16 grains, three times a day, and the comTo the Editor of THE LANCET. pound infusion of gentian substituted for the camphor mixture. Now and then she laid aside the iodine for a time, taking quinine SIR,- An abstract of the following paper was laid before the and iron in the intervals, and again resumed it. Nothing was Royal Medical and Chirurgical Society at the last meeting of the I shall feel obliged by your publishing it entire in applied to the tonsil. The discharge, which had continued almost THEsession. as it appears to me that the merits of the case, if LANCET, and for many months, gradually diminished, constantly finally be developed in a few lines. could not any, ceased. During this treatment she had no relapse of any imI am, Sir, your obedient servant,

portance, and at the end of five months was perfectly restored to health and spirits. Three years have since elapsed, and she has not had a single attack. Lately she has been under my care with dysmenorrhcea and ovaritis, brought on, I have reason to believe, by anxiety of mind. I believe that the action of iodine in cases like the one just .described, is that of a general tonic and alterative. Iodine is un,do.ubtedly a powerful alterative, and in many diseases, particularly when they occur in scrofulous subjects, prepares the way for the action of tonics of another class, which, without its use, often fail in their operation. August 5th, 1845.

Dean-street, Soho.

ROBERT WADE. IN a recent valuable communication to this Society by Mr. Luke, its attention was called to an occurrence which occasionally happens in strangulated hernia, when the hernial tumour, with its investing sac, is reduced through the aperture of the abdominal parietes, the hernial contents still remaining subject to strangulation from the same cause that existed previously totheir reduction. Having lately had to operate upon a hernia of this kind, which was attended with some little difficulty in the diagnosis, I have ventured to present a description of the case to the Royal Medico-Chirurgical Society, trusting that a faithful narration of the circumstances as they occurred may not prove useless. INGUINAL HERNIA, WITH ARTIFICIAL ANUS In the afternoon of April 4th, 1845, I was requested to visit FOLLOWING THE OPERATION. Mr. B-, of Great Randolph-street, Camden-town, in consultawith Mr. Mullins, of Kentish-town, and Mr. Davey, of By CHARLES A. DALBY, Esq. Surgeon, Ashby-de-la-Zouch. tion Great Ormond-street. The patient, an active, healthy man, in his ON the 26th of January of the present year, I was sent for early seventy-fifth year, had been affected with inguinal hernia on in the morning to see Sarah P-, aged sixty-eight years, who both sides for nearly thirty years. The hernlae were sometimes was said to be in a state of considerable alarm about a tumour as large as a good-sized pear, occasionally descending into the which she had just discovered in the right groin. On examina- scrotum, but were always easily reduced, and generally kept up .tion, I found this to be a small inguinal hernia, which felt ex- by a double truss. I was informed, that two days previous to my ceedingly firm and unyielding under pressure, but unattended visit, Mr. B-, on getting out of bed in the morning, expewith severe pain. She had not had any evacuation from the in- rienced a slight but momentary darting pain in the right inguinal testines for four days, and her abdomen was greatly distended, region; that on going to the water-closet soon afterwards, as but she remained free from sickness and fever. I immediately was his usual custom, he found that his bowels would not act-an instituted both the internal and external means usually adopted unusual circumstance with him. Towards the afternoon he began in such cases for emptying the bowels and bladder, and for to vomit, the fluid ejected soon became stercoraceous, and at facilitating the reduction of the tumour by the taxis. This object my visit had a highly feculent smell and appearance ; the breath was also very foetid. was continued throughout this and part of the following day, Upon a careful examination, not the without producing the desired effect. About midday of the 27th, slightest appearance of hernia could be detected on either side, she was seized with vomiting and hiccup, and increasing pain in nor was there any tenderness on very firm pressure over the the groin. It now appearing to me that reduction by the taxis inguinal canals, or any part of the abdomen ; the pulse was about was impracticable, I sent to request the assistance of my partner, 90, regular, and tolerably full, except during the sickness, which Mr. Kirkland, who, in consultation, coincided in opinion with caused great faintness. Cathartic enemata had been administered, me, that the operation for necessary, as affording the and croton oil, a scruple dose of calomel, and other powerful puronly chance of saving the patient’slife. As soon as gatives taken, without producing the desired effect. It was evident could be made, this was performed in the afternoon, in the ordi- that there was obstruction in some part of the intestinal tube, and but little doubt could be entertained of the seat of the obstruction nary manner. I made a long incision through the integuments, and on being in one of the herniæ. There was nothing, however, to guide exposing the tumour, found it intimately attached to the sur- us to the exact locality of the strangulation, with the exception rounding parts by remarkably firm and evidently old adhesions. of the before-mentioned slight darting pain in the right inguinal It was with extreme difficulty, with the finger and handle of the region felt by the patient on first getting out of bed. The scalpel, that these could be separated, so as to admit of the stric- spermatic cord was certainly more distinctly felt on the right ture being divided; and even after this was done, there were side than on the left; and, from all the circumstances of the case, remaining strong adhesions, which occasioned much embarrass- I was led to the conclusion that the right hernia, with its investment, and resisted for a long time every attempt to divide them. ing sac, had been reduced en masse by the patient, and- that the However, this in the end was surmounted, and the herniary pro- obstruction existed in the neck of the sac on that side. As, howtrusion completely reduced. I then dressed the wound in the ever, it was the opinion of the gentlemen present, as well as my usual manner, and the patient was placed in bed without any un- own, that the symptoms were not yet sufficiently urgent to warpleasant symptom. She passed the night in a somewhat restless rant any immediate operative procedure, we agreed to give the condition, but without fever. Next day, finding the bowels were patient small doses of Epsom salts in a little mint-water, and to quite inactive, I gave her an enema, but as this produced no continue the administration of purgative enemata. On my next visit, at three o’clock the following day, with Mr. effects, it was repeated three times in the day for some days, and still without proving effective. About the third day after the Mullins, who had the immediate charge of the patient, we found operation, sickness, with vomiting, supervened, and fsecal matter him rather more exhausted than the day before; his bowels had On the 4th of February, not acted, and he was exceedingly desponding, feeling persuaded was frequently rejected by the mouth. that he should not survive his present illness. He had passed a a rupture of the intestine at the seat of operation took place, and the alvine contents were passed through the orifice, which thus restless night, occasionally talking to himself, and had been much formed an artificial anus. On this, the vomiting and all other harassed by vomiting ; his tongue was dry, and rather brown in the centre, but the pulse, except during the sickness, continued unfavourable symptoms ceased. In this state the poor woman continued till the middle of May, pretty good, being about 90, and there was not the slightest when a natural evacuation from the rectum took place, without tenderness on firm pressure in any part of the abdomen, nor the aid of any medicine. From this time to the end of June she could any tumour be felt in the neighbourhood of the rings. The continued to have motions daily ; sometimes from the wound in patient was assisted out of bed and made to cough, but although the groin, which remained partially open, and sometimes through the hernia on the left side was forced down, there was no descent the natural passages. About the middle of July, the external on the right; the attempt, however, could not be persevered in, wound was closed, and up to the present time, she has had natural for he soon became so faint as to fall backwards on the bed with evacuations without assistance. In all other respects, she enjoys a pulse scarcely to be felt. Although the symptoms indicated as good health as most people of her age, having a good obstruction of the intestinal contents rather than any serious mischief of the intestine itself, yet, taking into consideration the appetite, sleeping well, and being free from pain. August 6th, 1845. exceedingly depressed state of the patient’s nervous system, the

hernia was

preparations

I

.

179 extremely harassing sickness from which he had now for some hernia was found placed immediately behind the external ring, length of time suffered, as well as his rather advanced age, with a stricture still existing at the mouth of the sac. Mr. Lawbesides the little probability there existed of producing any rence observes, in his °° Treatise on Ruptures," that he had never evacuation of his bowels from a continuance of the present mea- seen a hernia reduced in a mass in the living body, nor any sures, it appeared highly desirable that some more efficient example of such a reduction in pathological collections, butmeans should soon be adopted for his relief. I therefore pro- quotes the following case from the Medical Gazette, described by posed to cut down upon the right inguinal canal, to lay it open, Sir C. Bell:A patient was brought into the hospital, moribund, and endeavour to bring the hernial sac into view, so that it might and died, and we had an opportunity of examining him. He had .be opened; and, supposing that we were mistaken in our sup- been operated on by the taxis, and the surgeon was convinced position of the strictured intestine being on that side, then at the that he had done everything required of him. A tumour was same time suggested that the operation might be confidently ’, discovered quite within the muscular walls of the abdomen, which undertaken on the other. Mr. Mullins fully agreed with me in proved to be the strangulated intestine with the peritoneal sac, so this view of the case: the operation was, however, deferred that the surgeon had reduced the sac and the intestine within until nine o’clock in the evening, when Mr. Davey was to meet it ; and the stricture which produced the strangulation being in us, and it was proposed to administer, in the meantime, a tur- the mouth of the sac, there was no relief, and the patient died." pentine enema. - As the hernise were evidently returned within Dupuytren had seen six, and Sanson three, instances of the rethe abdominal parietes, we did not, for obvious reasons, recom- duction en masse. An example of the kind occurred to Le mend either the warm bath or tobacco injection. Before pro- Dran, which seems to have been the first recorded; another, to ceeding to the operation, at nine o’clock, when no favourable Scarpa; and one, also, to Sabatier. Mr. Luke has mentioned change had taken place, the patient was again assisted out of five cases, two post mortem, as having occurred under his own bed, and desired to cough, when the hernia on the left side observation, making in the whole twenty, including that dequickly descended, as before, and, after a little perseverance in scribed by myself, all of which, with the exception of two, which the coughing, assisted by pressure on the abdomen, the hernial were crural, seem to have been inguinal. The signs, which have tumour on the right side protruded about half an inch through been described by Mr. Luke and others, most to be relied upon, the external ring, but could not be made to advance further. as denoting the reduction en masse, are principally the absence On pressing the protruded parts between the finger and thumb, of that fulness of the ring and cord caused by the presence of the the patient said he felt a slight degree of tenderness, but so hernial sac, an unusual largeness of the aperture through which slight as scarcely to be perceptible, and very firm pressure around the hernia has descended, ascertainable by the introduction of the ring on either side did not cause any uneasiness. The abdo- the finger; a fixed, circumscribed pain in the neighbourhood of men had become a little tumid and tympanitic. The patient the ring ; and, in some cases, a tumour has been felt which has being placed with his legs hanging over the side of the bed, and been tender on pressure in the same situation, deeply seated his head and shoulders supported by pillows, the operation was within the abdominal muscles. A consideration of these cases cannot fail to suggest the necescommenced by transfixing a fold of the integuments over the right inguinal canal to the extent of three inches and a half. sity of the most careful examination being made in every inSome layers of fascia were then divided, and the inguinal canal stance where symptoms of internal strangulation are present; laid freely open by a division of the tendon of the external that we should, indeed, neglect no means in our power of asceroblique muscle. On opening the sac, which was much thickened, taining whether the mischief may not have arisen from the reand which closely embraced the intestine, about half a teaspoonful duction of a hernia en masse-a case fully proved to be within of a light-brown serous fluid escaped, and a small knuckle of the reach of operative surgery. intestine, rather red from congestion, was observed. The finger August, 1845. was then passed within the sac along the intestine, which, at the extent of about three inches, nearly as far as the finger could ON THE POWER, NATURE, AND EVIL, OF POPULAR reach, was found firmly embraced by a membranous band. This band was divided by a probe-pointed bistoury passed carefully MEDICAL SUPERSTITION. along the finger, when the strangulated portion of intestine was By SAMUEL FLOOD, Esq. Surgeon, Leeds. easily reduced. There was no omentum in the sac. The stricture was evidently formed by the neck of the sac, which could be IT is scarcely less humiliating than it is surprising, to reflect that felt completely surrounding the intestine, being very much the mind of man, with all its gigantic powers, and all the admirthickened and puckered at its under part. The wound was able aptitude which it displays for carrying out the great deunited by three sutures, with two or three straps of adhesive signs of the Creator, has nevertheless one general, if not univerplaster, the whole being secured by compresses and bandage. sal, failing point, evinced in a preference for the marvellous and The patient expressed himself as having obtained immediate the extraordinary, over that which is rational and plain. This fact has been admitted on all hands, and, indeed, has been relief from the operation, especially from his distressing sickness. April 6th, half-past nine A.M.-Has had a good night’s rest, and exemplified in all ages of the world, and has influenced, to a no sickness; pulse 90, improved in strength; bowels less disgreater or less degree, men of every grade and every capacity; tended ; no tenderness on firm abdominal pressure. No medicine for although it is true that superstition and credulity have usually has been taken since the operation. The bowels not having yet prevailed in proportion to the ignorance and general want of inacted, the following draught was ordered to be given every second formation of the people, yet is it equally true that they have enor

third hour until sufficient evacuations

were

obtained:-Sul-

phate of magnesia, a drachm; carbonate of magnesia, five grains; compound spirit of lavender, half a drachm ; syrup of orangepeel, a drachm ; distilled water, an ounce. April 7th, half-past twelve, P.M.-Bowels acted freely yesterday afternoon; pulse 90, of good strength; no abdominal tenderness ; wound nearly healed; the sutures were removed to-day. The only unfavourable symptom observed was a considerable degree of drowsiness, the patient requiring to be aroused to answer questions, which he then did very well, but quickly relapsed again into the same drowsy state. I did not again visit Mr. B-, but was informed, the following day, by Mr. Mullins, that the patient had passed a rather restless night, frequently talking incoherently to himself ; that his drowsiness had rather increased, although he stili answered questions very well on being aroused; the tongue continued dry; the pulse, however, remained good, and there

tenderness on firm pressure in any part of the I have lately heard that Mr. B- completely, but slowly, recovered. Although the reduction of the hernial tumour, en masse, does not appear to have been generally noticed by British surgeons ; yet Sir A. Cooper, in hisadmirable lectures on hernia, has alluded to the subject in the following words:—" The hernia may, apparently, be reduced" by the employment of the taxis, and strangulation still exist." This assertion is supported by the description of a case of the kind which occurred at Guy’s Hospital; but its true nature was not discovered until after death, when the

abdomen.

was no

The great the most erudite and learned men. Lord Bacon, for instance, believed in the virtues of charms and amulets, and the celebrated Mr. Boyle seriously recommended the thigh-bone of an executed criminal as a very powerful remedy. Nor is the fact I have named less true of nations than of individuals, for we find the very countries which boasted of being the repositories of learning, and knowledge, and literature, exhibiting instances of the most senseless and infatuated credulity: take, for example, the consulting of oracles, the patronage bestowed on magicians, astrologers, and so forth. Nay, to bring an instance nearer home, and nearer our own day, what can be thought of the condition of the public mind, when the existence of witchcraft was believed in ; and when that great and good judge, Sir Matthew Hale, absolutely condemned to be burnt many unoffending creatures for this imaginary crime? And much as we boast, in this our day, of progress in scientific research, of our general enlightenment, and of our high intellectual character, I believe it will be not very difficult to prove that we are, nevertheless, a marvel-loving race, delighting to believe in things improbable, prepossessed in favour of wonders and won-’ der-workers, and quite indisposed to be bound by matters of fact, or guided by the dictates of reason. " Man," says Southey, 11 its a dupeable animal; there is scarcely any one who may not, like a trout, be taken by tickling." Premising thus much as to our general proneness to superstitions belief, I propose to institute an inquiry into the nature of it; but as the whole subject would be far too comprehensive for the slaved

even

philosopher,