Elements of Surgery

by Robert Liston

AFFECTIONS OF THE ABDOMEN.

Inflammation of the peritoneum, when idiopathic, is generally treated by the physician. But it occurs in consequence of wound, obstruction from hernia, or affection of the lower bowels. There is a burning heat in the belly; the pain is constant and increasing, much aggravated by the slightest pressure or exertion of the abdominal muscles, and the patient, in consequence, lies with these muscles in a state of relaxation. The pain is of a very different character from that arising from spasm, induced by the irritating nature of the intestinal contents, which supervenes in paroxysms, and is relieved by pressure or by evacuation. In inflammation the countenance is very anxious, and generally pale; the extremities are cold and bathed in perspiration; the patient vomits frequently; and the bowels are generally constipated. The pulse is small, wiry, and rapid.

Hernia has been classed with tumours. It is a swelling, but of a peculiar kind, and attended in some states by peculiar symptoms. The term rupture is in common use instead of hernia, but was at first applied from a false notion of the disease. There is a descent of viscera, but not often rupture of the parietes. By hernia is meant protrusion or escape of the contents of any cavity, but the term is most frequently applied in regard to the abdomen. The protrusion may occur at various parts of the abdomen; through the diaphragm, constituting Phrenic Hernia; through the umbilicus, constituting Exomphalos; through the dilated apertures for transmission of vessels, constituting Ventral Hernia; through the inguinal canal, constituting Inguinal Hernia; through the crural aperture, constituting Crural or Femoral Hernia. The most frequent forms are the inguinal and crural,—the effects of pressure or action of the muscles on the abdominal contents being concentrated towards the lower part of the cavity. It is but rarely that the bowels protrude through the sacro-ischiatic notch, or through the obturator foramen, or by the side of the vagina, or betwixt the bladder and rectum.

It is of great importance for the student to study attentively and reflect on both the healthy and morbid anatomy of this disease. When a hernia is strangulated, there is an absolute necessity for early interference; the bowels are obstructed, and their action inverted; feculent vomiting ensues, and enteritis is threatened, with all its dangerous consequences. He may meet with the affection at a very early period of his practice, and may be so situated as to command no assistance or advice; he must be guided by his own judgment and knowledge. He should be well aware of the relations of the parts to each other, and the changes likely to have been occasioned by the disease. If, through delay, the patient lose his life, or if an operation be attempted, and its object improperly accomplished, or not accomplished at all, his reputation may be blasted. But if he interferes skilfully, and at the proper time, and save his patient, relieving him at once from all his painful and dreadful symptoms, great credit and professional fame may be in consequence acquired. An examination of the healthy anatomy is not sufficient; many changes take place, which mere anatomical and physiological knowledge could never anticipate. Extraordinary displacements and adhesions occur. The parts are altogether changed; and repeated examination of the morbid state alone can impart the requisite knowledge to one previously well acquainted with the healthy structure.

In consequence of laceration or separation of fibres, hernia may occur suddenly, and even in the best formed parts, from very violent exertion—as in leaping, wrestling, pulling, lifting heavy weights; from sudden exertion of the abdominal muscles in any way; from blows, &c. Or the protrusion may come on gradually, after slight exertions, where the tendons are naturally weak or deficient; or it may be slowly induced by repeated and almost constant muscular action, as in urinary, intestinal, and pulmonary complaints: in such cases, slight pain is usually felt at the site of the protrusion before the tumour is perceived. The disease is often congenital. But the common cause of abdominal hernia is powerful action of the abdominal muscles, compressing the viscera to a greater or less degree, and with more or less suddenness; the viscera resisting the compressing force, react on the parietes, and these, yielding at the points which are naturally weak or deficient, permit enlargement of the coerced cavity by protrusion of part of the contents. When the compression and reaction are sudden and violent, the protrusion is the same; but when the former are not sufficient to overcome the cohesion of the parietes by a single occurrence, by repetition the morbid end is gradually effected, the hernia is proportionally slow in making its appearance, and gradual in its increase.

To understand the nature of congenital scrotal hernia, the student must recollect that the testicle in the fœtus is lodged in the cavity of the abdomen immediately below the kidneys, and resting on the psoas muscle; that it gradually descends into a process of peritoneum, called spermatic, which extends from the general peritoneal cavity down towards the scrotum, and which ultimately constitutes the tunica vaginalis. The orifice of this peritoneal pouch not closing immediately after the descent, may permit a fold of intestine to slip into its cavity, and remain in contact with the testicle. Or the testicle may, though rarely, contract in the abdomen an adhesion to a portion of bowel, and in its descent bring this along with it. In either case the bowel remain in its new situation, and constitutes congenital hernia.

Hernia infantilis differs from the hernia congenita, and is a kind of protrusion peculiar to the early period of infancy. In the congenital form the protruded intestine is in immediate contact with the testicle, and surrounded by the tunica vaginalis testis; but in hernia infantilis a process of peritoneum is interposed betwixt the intestine and the vaginal coat. The affection occurs after the abdominal aperture of the spermatic process has closed, but before the rest of that process has become incorporated with the spermatic vessels and their surrounding cellular tissue. In fact, only the peritoneum proper has closed, and forms the septum between the cavities of the abdomen and of the tunica vaginalis; but being insufficient to withstand the impulse of the abdominal contents, yields before it, and descending along with the protruding portion of bowel, forms its envelope, or the proper hernial sac, within the cavity of the tunica vaginalis.

Such is the opinion generally adopted in regard to the nature of hernia infantilis; but its accuracy is doubtful. It seems more probable that the bowel, covered by a fold of peritoneum, is protruded into the cellular tissue of the spermatic chord, after closure and contraction of the spermatic process, and descending till it reach the upper and posterior part of the tunica vaginalis, adheres to this tunic, bulges it forwards, and is covered by it. On cutting down in such a case, the hernial tumour may appear to be lodged within the tunica vaginalis; whereas the bowel is actually placed exterior to the tunic and behind it. Indeed, the case is similar to the common scrotal hernia, only the tumour is behind, not anterior to the vaginal coat. And this relation of parts is more apt to occur in the infant than in the adult; for in the former the testicle does not for some time descend fully into the scrotum, and whilst it is lodged in the groin a fold of peritoneum protruded into the spermatic chord may soon contract adhesion with the tunica vaginalis, afterwards descending along with it and the testicle. The subjoined case, illustrative of the preceding statement, came under my observation in 1814.—J. S., æt. 21, was admitted into the Royal Infirmary, with symptoms of strangulation which had been of eight days’ duration. The hernia had existed from infancy; it was on the right side, and tolerably large. In the operation, on dividing the integuments and various coverings, a sac was opened, which proved to be the tunica vaginalis, containing the testicle, a considerable quantity of serum, and a large, smooth, transparent tumour above the testicle and behind the posterior layer of the tunica vaginalis. The operator was puzzled, but finally determined on cutting into this tumour; it proved to be the hernial sac, covered by the tunica vaginalis, containing three or four ounces of serum and a portion of omentum. The protrusion could not be returned; after relieving the stricture, the omentum was cut away, and the bleeding vessels tied separately. The patient died on the third day after. An analogous case is on record; and a third has been related to me by an old and experienced surgeon: in that instance, both the anterior and posterior layer of the tunica vaginalis, together with the true sac, were simultaneously divided; omentum and intestine protruded into the vaginal coat, and for a time the opening through the posterior part of that cavity and sac was mistaken for the inguinal ring. On extension of the incision, the nature of the case became more apparent, the stricture was relieved, and the protrusion reduced. A case, in many respects similar to those above described, occurred a few years ago in my practice at the North London Hospital. It is recorded in the Lancet and in the Practical Surgery.

Children are sometimes born with deficiency of the umbilicus, and protrusion of bowel into the loose cellular tissue of the umbilical chord; the disease is termed congenital exomphalos.

Almost all the viscera of the abdomen and pelvis are liable to protrusion—the stomach—the spleen—the omentum—the great and small intestines, and even some of their most fixed parts—the ovaria—the bladder. Also, right portions of the viscera occasionally escape on the left side of the parietes, and the left at the right.

Hernial protrusion has received different names, according to the nature of its contents. When composed of a portion of intestine, it is termed Enterocele; Epiplocele, when composed of omentum; and Entero-epiplocele, when both intestine and omentum have escaped; and, as already observed, different names are also applied, according to the situation of the protrusion.

The inguinal and crural forms of hernia being the most common, will chiefly occupy our attention. The inguinal is divided into true or oblique inguinal, and into direct or ventro-inguinal. In the oblique, the protrusion passes along the inguinal canal. This course is in young persons short; but as the muscles become developed it is lengthened to about two inches, reckoning from the external ring to the funnel-like opening through the transverse fascia. The appearance of the swelling in this canal leads to diagnosis betwixt the oblique and direct hernia; but in chronic cases, this distinction is often in a great measure done away with. In large and old oblique ruptures the neck of the tumour is shortened, and the openings of the canal are approximated and more in a direct line. They are also immensely dilated, being often enlarged to such an extent as to admit all the fingers of the hand, when placed in a conical form,—and this even in the living body, the loose integument receding along with the tumour. The epigastric artery is situated behind the neck of the sac, on its inner side; and it is much displaced inwards in cases of old standing. The direct hernia passes through the parietes opposite to the external ring, and does not come in contact with the spermatic chord until it has reached that point. Its neck is short, and the epigastric artery is on its outer side. The coverings of the two tumours are different. Those of the oblique are such as the chord possesses—a prolongation of the transverse fascia, a covering from the cremaster muscle, fibres from the edge of the external ring, and the superficial fascia of the abdomen. The direct has only the last. A very old woman was operated upon in the North London Hospital a few days ago, for strangulated hernia of several days standing. The tumour was high in the inguinal region: on cutting down upon it, the tendon of the external oblique was found to cover it completely. The external ring was occupied by a mass of fatty matter, which probably had been displaced. The tendon was divided, and the sac, of considerable size, exposed. The opening through which the protrusion had taken place was very small, and situated a good deal to the mesial line of the internal aperture of the canal. The hernia was at the time of operation supposed to be ventro-inguinal. The patient was relieved for a time, but eventually sunk exhausted. An opportunity was thus unfortunately afforded of verifying the opinion formed. The hernia had two proper coverings, the superficial abdominal fascia and the tendon of the external oblique. The opening was inside the epigastric. The portion of bowel which had been extruded and returned was very tender, but it had adhered to the peritoneum, close to the place where it had been confined.

The oblique inguinal, when recent and small, is termed Bubonocele; but when large, it generally descends into the scrotum—oscheocele—of course exterior to the tunica vaginalis; and in females into the labium. The tumour often attains an immense size, from continued application of the causes that produced it,—laborious occupations, or straining of muscles in any way. When of long duration, and not attended to, it is not uncommon for the swelling to hang as low as the middle of the thigh, or even down to the knee. In such cases, the testicles often are wasted, and the penis concealed; indeed the skin of the penis, as well as of the lower part of the abdomen, is stretched over the tumour. Crural or femoral hernia is, on the contrary, seldom larger than a small apple. Sometimes, but very rarely, the tumour is of large dimensions. I have seen one containing the transverse arch of the colon, the omentum, and a yard and a half of small intestine. The tumour is represented some pages further on.

When a very large hernia remains always full, the cavity of the abdomen diminishes in size; in fact, it adapts itself to its contents; and this must be kept in mind when interfering with such cases.

Inguinal hernia most frequently occurs in males, the femoral in females; and the reason of this is obvious on comparing the size of the inguinal and crural openings in the sexes. In the male, the inguinal opening is much larger than the femoral; in the female, the femoral is the larger,—the inguinal is small, containing only the round ligament of the uterus. The causes of hernia act equally on both openings, and therefore it is to be expected that protrusion will take place where there is the least resistance, where the parietes are most deficient.

Hernia can seldom be mistaken for any other swelling, by one at all acquainted with his profession, and who makes his examination attentively. The history, and the mode of its appearance, are to be attended to. The swelling proceeds from above—at times it recedes on the patient lying on his back and making pressure on the swelling—a distinct impulse is communicated to it on exertion of the abdominal muscles, as in coughing—the tumour is generally elastic, and its neck can be felt extending from the lower abdominal aperture. Also, the two kinds, inguinal and crural, can scarcely be confounded with each other; the former is above, the latter below, the ligament of Poupart. It will be proper, however, to enumerate shortly the diseases for which hernia may be mistaken.

Cirsocele may be confounded with inguinal hernia. Cirsocele, being a varix of the spermatic veins, enlarges on coughing and during the erect posture, like hernia; but in general the composition of the tumour can be ascertained by the feel which it imparts when handled,—the veins feel like a handful of earth-worms. Besides, the swelling is made to disappear, on emptying the dilated veins by pressure upwards; and, if the surgeon then firmly compress the inguinal aperture, the tumour will rapidly reappear, on account of the venous flow being interrupted, particularly if the patient exert his abdominal muscles, or assume the erect posture. Whereas, had hernia existed, the swelling could not have been reproduced; and, on the patient being directed to cough, a distinct impulse would have been felt with the finger. Hydrocele of the tunica vaginalis may be confounded with scrotal hernia, if its distinctive characters be not understood or attended to. The pyramidal swelling presents an equal surface, fluctuates, and is generally diaphanous; its formation is gradual, commencing at the lower part, and slowly ascending; the testicle cannot be readily felt at the bottom of the scrotum; there is no swelling at the inguinal canal, and the chord is felt free; the tumour is not affected by the position, motion, or exertions of the patient. These circumstances plainly indicate the nature of the case. Bubo, sarcocele, and acute swelling of the testicle, are sufficiently distinguished from hernia by their situation, form, feel, and history, and cannot be confounded with it save by the profoundly ignorant. Hydrocele of the spermatic chord is more likely to lead to deception when large; but it is generally small and circumscribed, involving the middle of the chord, leaving the inguinal aperture free, and the upper part of the spermatic chord distinct. Besides, whatever may be its size, its formation is always slow and indolent,—it is never capable of being pushed into the abdomen, and it is unaffected by those circumstances which contribute to mark hernia. But hydrocele of the chord and hernia may coexist, as in the following instance:—A gentleman had swelling in the course of the spermatic chord for many years, while in a warm climate. Bandages were applied, and great pain thereby occasioned. After his return to this country, pain in the belly and vomiting seized him on a Monday morning, and continued with more or less violence till the Sunday following. Then the vomiting became feculent, the belly excruciatingly painful and tender, the tumour tense, and the pulse weak. A physician opposed operative measures, having been convinced that his former complaint was a hydrocele of the chord. But I conceived that the symptoms warranted cutting down on the parts, and did so. A hernia was found containing omentum and a fold of bowel; a hydrocele of the chord lay alongside of it.

Crural hernia has been mistaken for bubo, and vice versâ. Lumbar abscess and varix of the femoral vein are also supposed to resemble it in some measure. The situation and form of the tumour in lumbar abscess is very different from those of hernia; and the mode of examination recommended in regard to cirsocele is equally applicable to the detection of dilated femoral vein. The distinctions between crural hernia and bubo are too obvious to require mention.

Patients with unreduced hernia are constantly in great danger; as bruising of the swelling, or accumulation of feces in the protruded bowel, are likely to occasion very unpleasant consequences. They are generally troubled with indigestion, flatulence, and constipation; a slight degree of constriction at the neck of the tumour produces an obstruction to the intestinal contents; the viscera in the sac have not due support and pressure, hence accumulations take place in them, and may be productive of serious and even fatal effects. No protrusion, in which these circumstances are likely to occur, should be allowed to exist, if possible. So afraid were the ancients of allowing hernia to remain unreduced, that it was their custom to cut all patients labouring under rupture who would submit to the operation; and this was generally performed by itinerant quacks. They returned the protrusion without opening the sac, and then the neck of the tumour was either stitched up, or tied along with or without the spermatic chord. The actual cautery, and the most powerful caustics, were also applied to the parts by some, and dreadful were the effects; yet after the neck of the sac had been destroyed, and perhaps the bone exposed and exfoliated, protrusion again took place by the side of the cicatrix. By many, castration was considered necessary for the cure of scrotal hernia. Such harsh measures were founded on erroneous and imperfect ideas of the nature of the disease, which are not often to be met with in the present day. Operations for unincarcerated hernia are not justifiable, and those who have operated in such circumstances give a very unfavourable account of the experiment.

The external applications employed to reduce hernia are various. Some are supposed to produce corrugation of the integuments, and contraction of the cremaster muscle, and thereby to force up the protruded intestine; others are of an astringent character, and their administrator may gravely believe and say, that by them he expects to tan the living scrotum, to reduce the hernia, and to present an insuperable obstacle to its reproduction. But all such means are visionary, and practically ineffectual; no external or internal remedy can attenuate and reduce the hernial sac, remove adhesion, or produce contraction of the tendinous and rigid apertures.

Herniæ are either reducible or irreducible. A hernia is said to be reducible, when the protruded bowel or viscus readily returns into the abdomen on the application of pressure to the swelling, or on the patient assuming the recumbent posture. When recent, the swelling may not be made to disappear without considerable difficulty; but, after the disease has become of long duration, the aperture through which the protrusion has taken place dilates and is relaxed, and admits of the ready passage of the hernial contents: such tumours are usually of considerable size. But reducible herniæ should not be permitted to enlarge, since their protrusion can be prevented by simple and safe means; after reduction, a properly fitted bandage, termed a Truss, is applied over the aperture and canal, and by the compression thus made the opening is rendered impervious to the abdominal viscera. In inguinal hernia, the pad of the truss must make equable compression over the whole of the canal; in the other species, the aperture is less extensive, and the pressure more direct. Perseverance in the use of a well-adapted truss is highly necessary in children from the first, so that a chance may be afforded of permanent cure by contraction of the opening and development of the surrounding parts. In young persons the canal is short, and almost direct, and from its becoming oblique and elongated during growth, prevention of protrusion may be effected. Descent must never be allowed during such attempts at cure. But in adults such a fortunate result can scarcely be expected; the truss must be constantly worn during the day—in bed it may be disused—and the patient must rest satisfied with thereby escaping those dangers to which protrusion of the hernia would render him always liable. Great care should be taken to ascertain in the morning, before the truss is applied, that no protrusion exists. If the opening be not much dilated, it may contract even in adults when protrusion is sedulously prevented. The patient will also require to avoid the causes of hernia. If he is subject to cough, or labours under bad urinary disease, by which the abdominal muscles are called frequently and fully into action, there is no chance of a cure; nothing but the continued use of a truss will afford safety.

Hernia is rendered irreducible, 1. By the formation of adhesions between the sac and the included parts. 2. By induration of the protruded omentum, and by accumulation of fat in it, or in the appendiculæ of protruded large intestine. 3. By contraction of the abdominal cavity from long-continued displacement of a large portion of its contents. 4. By the nature and connexions of the protruded part, as in hernia of the sigmoid flexure, or of the caput cœcum coli. 5. By firm compression of the abdomen. 6. By the tightness of the opening giving rise to engorgement of the protruded parts. 7. By accumulation of feces, solid or fluid, in the protruded portion of bowel. With care, some of these causes may be got over, and the tumour reduced. In irreducible hernia the use of a bag truss is indispensable to prevent increase of the protrusion. In irreducible femoral hernia of small size, a hollow pad with a weak spring is used with advantage, to give support to the contained parts, prevent farther protrusion, and guard the tumour against external violence. The patient must avoid violent exertion, keep his bowels open, and be careful of his diet; he is always in danger, and should know it. Many have lost their lives from blows otherwise not dangerous; and even straining at stool is sufficient to force additional portions of viscera into the neck of the sac, and thereby induce most serious distress. Ruptures often come down during an attack of bowel complaint, or after a dose of purgative medicine.

The term incarceration of hernia is employed to indicate a slight degree of strangulation, when the hernial contents are confined from any cause, and when the circulation in the protruded bowel and the course of the feculent matter are nevertheless uninterrupted. By many it is applied indiscriminately with strangulation.

Strangulation arises, not from any change in the neck of the sac or in the tendinous aperture, but from increase of volume in the protruded parts, caused by accumulation of the solid, fluid, or gaseous contents of the bowel, followed by interruption to its circulation; or the interruption to the flow of blood may precede the distension. The circulation is more readily retarded or arrested in the veins than in the arteries, and consequently the engorgement of the bowel is at first caused by venous turgescence; but when the flow in the arteries is at all impeded, the infiltration and exudation become more rapid, and the part quickly perishes—sphacelates. The symptoms which accompany and indicate strangulation are of a very imposing nature, and cannot be neglected; and it is fortunate that such is the case, for no disease is fraught with greater or more immediate danger to the patient, or requires more the early interference of a skilful and expert surgeon. The tumour becomes tense and painful, and the integument is sometimes red and shining; the pain is much increased by pressure, and extends over the abdomen, but continues most severe near the neck of the swelling; sickness and inclination to vomit quickly follow; the patient feels languid; his countenance soon assumes a contracted anxious appearance; the circulation is hurried; the pulse beats wiry and hard, though at first it may have been full. If relief is not afforded, all the symptoms are speedily aggravated; vomiting comes on, and is frequent; no discharge can be procured from the upper bowels, though the lower may be, and often are, evacuated by injections or by natural efforts: if the upper bowels evacuate downwards, the strangulation cannot be of the whole calibre of the gut, but only of a part. Pain and heat in the tumour and belly increase; and the former becomes very tender, and tense as a drum. The circulation is more hurried, and restlessness and intolerable anxiety supervene. The patient becomes worse and worse every hour; feculent matter in large quantity is vomited or gulped up with great distress, and is commixed with bile, with vitiated mucous secretion from the stomach and bowels, and with whatever may have been recently swallowed; in fact, the peristaltic action of the alimentary canal above the strangulated part is inverted, and all the contents are ejected. Troublesome hiccough comes on, and this symptom is by many considered as a sure sign of gangrene having taken place; but it is often present when the bowels are quite free from tenderness or tendency to gangrene. The extremities grow coldish; the pulse is unequal and fluttering, and with difficulty counted at the ankles. The countenance sinks, and assumes a leaden hue; the pain abates suddenly; the eyes are glassy; the tumour becomes flaccid, and is often livid and emphysematous. Now, the bowel may recede, and feculent evacuation take place, with some relief; but the patient, after lying some time insensible, expires. All this may occur, either within a few days after the occurrence of strangulation, or not till after the expiration of many days. The rapidity of the symptoms and the danger are influenced by the size of the tumour and the condition of its neck, and by the nature of its contents. In small recent herniæ, the advance from bad to worse is usually very rapid, the aperture through which protrusion has taken place being small, and producing a great degree of constriction when distension and engorgement occur. When the neck of the tumour is large, and completely occupies the aperture previously to the strangulation, the progress of the symptoms is also rapid, for a similar reason; but if the hernia be large and of long standing, and if the protruded parts are not bulky at the point of protrusion, the constriction is in general not very severe, and the distressing consequences advance more slowly. The symptoms are not so violent in epiplocele as in enterocele. In many instances of the former, the intestinal discharges are never obstructed, though great irritation and inflammation may be induced by the strangulation. There is also less danger in entero-epiplocele than in enterocele, compression of the bowel being in the former instance diminished by the intervening omentum.

It is scarcely necessary to observe, that, when the train of symptoms just detailed commences in any case, the surgeon must immediately and anxiously inquire as to the existence of external hernia, for often the disease is concealed, particularly by females: all parts where protrusion is likely to occur must be examined attentively. At the same time, the surgeon must bear in mind that pain of the abdomen, with symptoms resembling those of strangulation—in fact, that enteritis, with obstruction, may exist along with hernia, but independent of it. A person with hernia is as liable as any other, if not more so, to inflammatory attacks in the abdomen from a variety of causes. The portion of bowel in the tumour may participate or not in the general abdominal affection; if unaffected, it may be reduced; it is neither painful nor tense. Again, in large ruptures, inflammation of the contents may take place without strangulation, and without affection of the parts within the abdomen. All circumstances bearing on the case must be well considered by the surgeon, before making up his mind as to the nature of the affection.

Returning the contents of the hernia into the abdomen is the only effectual means of counteracting the direful effects of strangulation; and the propriety of an early recourse to this measure must be quite apparent. It is indispensable, and no delay is warrantable. The means for accomplishing it must be varied, according to the state of the parts, the duration of strangulation, and the general symptoms. The most simple method, and that which should first be attempted in ordinary cases, is the taxis; that is, reduction by pressure with the hand. In this, the position of the patient is of importance; it should be such as effects relaxation of the tendinous structures through which the hernia has protruded, and through which it is to be returned. With this view he is placed on his back, with the shoulders and pelvis elevated, and in crural hernia the thigh is bent on the trunk, and turned towards the opposite side; thus the aperture is relaxed along with the fasciæ which compose it. Long ago, the positions into which the patients were forced for the cure of hernia were various, and generally awkward; they all tended towards more or less complete inversion of the erect posture, and thus it was supposed that the abdominal bowels dragged on those protruded, and thereby assisted reduction. But the viscera are equally pressed on in every position of the body; it is not they, but the external parts, that are affected by change of posture. During the attempts at reduction, the patient should be exhorted not to strain or resist, but to relax his muscles; and it will be well to engage him in conversation, that he may not have an opportunity of keeping his lungs distended, and thereby acting forcibly on the abdomen. At first the pressure should be general, applied either with one hand or with both, according to the size of the tumour, so as to diminish the contents. If air be heard gurgling at the neck of the swelling, the chance of success may be considered good, for a return of part of the bowel’s contents is thereby indicated. Then a gentle kneading should be made at the neck with the fingers of one hand, while with the other general pressure is kept up. The impression made is at first slight and gradual; but, when a portion of the bowel returns, the rest of it slips up suddenly. The return of omentum is always slow, and the last part requires as much manipulation as the first. The direction of the pressure must be varied according to the case. In inguinal and ventro-inguinal hernia, it is made in the direction of the neck of the sac; in the former upwards and outwards, in the latter upwards and backwards; and previously the body of the tumour should be brought into the same line with its neck. In crural hernia the pressure must first be made towards the centre of the thigh, so as to bring the whole tumour into the same direction with its neck, and then upwards. In umbilical, the pressure is straight backwards. Small herniæ, and those of recent origin, are with difficulty reduced; their neck is narrow, and the passage proportionately small; the crural are usually of this description. In all herniæ, after strangulation has existed for some time, and adhesions formed, particularly at the neck, reduction is almost impossible.

The taxis is to be neither attempted nor persevered in after the hernia has become tender and inflamed. No good can be done by it, and the patient’s chance of recovery by operation is much diminished. Even when no pain is felt in such circumstances, any degree of force must be prejudicial. Mortification of the bowels is often hastened in consequence of the taxis being unskilfully employed by ill-informed persons, who are often determined, at all risks, and at all stages of the affection, to accomplish speedy reduction of the viscera. The surgeon will take care to inform himself of all particulars—as to the duration of strangulation, the previous state of the tumour, if it was all, or only in part reducible, as to its size, &c.—before proceeding in any way. Great mischief is likely to accrue from the tumour being handled, perhaps roughly, by many people. If the taxis is gone about, however, in proper time, and in the right way, it ought almost always to prove successful. It is very desirable indeed that this should be the case, seeing that all the bad symptoms in ninety-nine out of a hundred cases instantly subside; whereas, after the reduction by incision, there is always great risk from the opening of the peritoneal sac alone.

Certain means may assist the taxis, but they should not be long continued or often repeated. Venesection can be employed only in strong plethoric patients, in the very first stage of strangulation, and before the patient is exhausted by the distressing symptoms. It is had recourse to in order to induce syncope, or an approach to it; during which general relaxation takes place, and reduction may be attempted with advantage. With that view the patient is placed erect, and a large orifice made in the vein of one or both arms, so that a moderate quantity of blood suddenly abstracted may have a powerful effect on the system. In several cases I have found this practice beneficial, but am inclined to say that, in general, it will not be followed with success. In a favourable case, one attempt of this kind may be made, but not repeated. In many states of the constitution, and in the latter stages of the disease, bad consequences must follow the practice. But in regard to it or any other remedy, it would be folly to lay down positive general rules; what may prove useful in one or two instances may answer very badly in the majority of cases that come under treatment. Local bloodletting can have no effect in diminishing the size of strangulated parts; though in inflammation of the contents of the tumour, without strangulation, no more powerful means can be employed.

Purgatives have been recommended with the view of extricating the bowel by increased peristaltic motion; but the symptoms will, to a certainty, be aggravated by their use. Purgative enemata can do little good: if in small quantity, they empty only the rectum; if large, they may reach the strangulated part, but will scarcely have the effect of extricating it.

Emetics, in full or nauseating doses, have been supposed to be indicated in this affection as well as in ileus; but there is in general enough of sickness and vomiting without them, and it is often difficult enough to allay the vomiting even after removal of the obstruction.

The warm bath is greatly trusted in by some, and in many cases it proves a valuable and useful auxiliary to the taxis. It acts beneficially by inducing general relaxation, or even syncope; during which, whilst all resistance of the compressing powers upon the contents is suspended, pressure on the tumour can be employed to good advantage. By steady perseverance, whilst the patient is in the bath, a great majority of strangulated herniæ may be reduced. But neither the general nor the local application of heat, or any other known means, save the edge of the knife, can relax tendinous apertures farther than can be effected by attention to position. Irrecoverable and most precious time may be wasted in preparing the bath; and for this reason such means should never be resorted to, unless they can be commanded at the shortest notice.

Fomentation can do no good. The apertures can be neither relaxed by heat, nor contracted by astringent applications. By the local application of heat, the size of the parts composing the hernia will be augmented, the flatus being rarified, and the effusion and engorgement encouraged.

The cold bath, and the dashing of cold water on the surface, near the seat of the disease, have been tried in some rare cases with most marked success; but this is a practice not generally to be relied on. It can act only by producing sudden and powerful contraction of the coverings, and uniform pressure thereby on the contents. It is, perhaps, only applicable to scrotal hernia. Cold has been applied to the tumour, and even ice, so as to produce frost-bite, but little faith can be placed in such; the practice becomes dangerous after inflammation has existed for some time, the application diminishing the weakened powers of the parts, and accelerating gangrene.

Opium has been given by the mouth, and tobacco by the lower extremity of the alimentary canal; the former may sometimes prove advantageous, but the latter had better be dispensed with. The tobacco is thrown up either as an enema, or in the form of vapour; but the former method is generally preferred. A drachm of the leaves is infused in a pound of water for ten minutes, and one-half of the liquid injected; if this prove insufficient to prostrate the patient, the rest is administered after the lapse of a short interval. But many people have thus been poisoned, and the indiscriminate employment of the supposed remedy cannot be too strongly reprobated; its effects are most severe and unmanageable; the state of collapse is most complete and alarming, and it is often difficult, if not impossible, to bring the patient out of it—to procure reaction. In some cases reduction may be accomplished during the state of extreme debility which follows its use, but I have often seen it fail, and have witnessed the operation afterwards performed on the patients, who were at the time without pulsation, and from whom little blood flowed after the incisions; they never, of course, rallied, and sunk rapidly. Indeed the patient is always in a very unfavourable state for operation after the exhibition of the tobacco enema, though certainly in a very favourable state for reduction being attempted. The strong objection to the medicine I conceive to be its being so extremely unmanageable; it is impossible to say whether the depression of the vital powers that must ensue will be just sufficient to induce that relaxation and debility necessary or favourable to reduction, or whether it will proceed uncontrollable to such a degree as to extinguish life. In general it produces intolerable nausea and depression, universal relaxation of the muscles, coldness of the surface, with clammy exudation, vomiting, violent retching, vertigo, and perhaps insensibility. Were I so unfortunate as to be the subject of strangulated hernia, I should certainly have no tobacco used. After unsuccessful trial of the taxis, I might submit to be bled ad deliquium, and have a surgeon to attempt reduction during syncope; if somewhat more advanced in life, I should prefer the warm bath; if taxis then failed, I should certainly be operated on in a very few minutes afterwards. If the surgeon, after mature consideration, make up his mind as to the course of practice he would wish pursued in his own case, he will be fully alive to the necessity of impressing the utility of it on his patients, and have little difficulty in persuading them to submit to his proposals. No time should be dissipated in administering purges or clysters, or in cold or warm applications.

If the tumour is not very tender, make one good trial of the taxis, not long continued; if a warm bath can be readily commanded, place the patient in it, and employ the taxis when he begins to feel faint. If foiled, and if the patient can bear depletion well, the strangulation being recent, try a full bleeding to syncope; it may save depletion afterwards, and at all events the patient will be none the worse for it. Having failed, as may probably be the case, operate without delay.

The operation, as regards the immediate consequences, is neither formidable nor dangerous of itself; the delaying of it is attended with the most serious and irretrievable mischief. It ought to be performed within a very few hours after the occurrence of strangulation, and, in most instances, without putting off time with the means considered auxiliary to the taxis. Under urgent circumstances, it may be necessary to operate within a quarter of an hour after seeing the patient, as I have often done. In ordinary cases, time must be taken to converse with the patient and his friends, to convince them that all those means likely to assist reduction, and render an operation unnecessary, have been tried. The surgeon must not appear to be in a hurry, though he puts off no time unnecessarily; otherwise his motives may be misconstrued.

The necessity for operating early is greater in small than in large herniæ, in crural than in inguinal. The groin and neighbouring parts are to be shaved, and the patient placed in the recumbent posture, with the shoulders slightly elevated. The mode of operation must be varied according to the nature of the tumour, its size, and other circumstances.

The operation for inguinal herniæ is conducted as follows:—The patient is placed recumbent on a table, or, in private practice, on the side of a bed, his shoulders supported by pillows, and his feet resting upon a stool. An incision is commenced about an inch above the external abdominal ring, and continued to the bottom of the tumour. This latter part of the procedure, however, is applicable only to small and moderately-sized herniæ; in large tumours the wound is not made so low, for in them the bowels may be irreducible, from the quantity protruded, and the contracted state of the abdominal cavity; in such cases the incision should be only to such an extent as is sufficient to enable the operator to reach the stricture. The first cut is carried through the skin and fatty matter, not deeper. The layers are then divided successively, with the hand unsupported; and this is done only at the middle and projecting part of the swelling. It is unnecessary to prolong the incision of the layers along the whole extent of the wound in the integuments, at this stage of the proceedings. In the direct hernia, which is of rare occurrence, there is but one proper layer,—that furnished by the superficial abdominal fascia: not unfrequently there is an imperfect additional envelope, furnished by fibres from the edge of the external ring; sometimes the tumour does not escape through the external ring, and is then of course covered by the tendon of the external oblique; of this I have seen but one instance, and that in a female; but in a common inguinal hernia there are three or four, and these are thickened more or less according to the size and duration of the tumour. The division of these layers must necessarily be conducted with great care and caution. At length the sac is exposed. This is opened by pinching up a portion betwixt the nails of the thumb and forefinger, or with dissecting forceps, and then cutting with the blade of the knife laid horizontally. On wounding the sac, there is usually evacuated a small quantity of brownish serous fluid. The probe-pointed bistoury is then taken up, and insinuated into the opening; and by this instrument, guided on the forefinger of the left hand, the sac and its coverings are divided up to near the ring, and down to near the bottom of the tumour. The hernial contents are thus exposed. These are unravelled, and examined attentively; if only brownish-red, from accumulation of the venous blood, of unbroken surface and unadherent, they are fit to be reduced. The stricture is felt for with the forefinger of the left hand, and into it either the point of the finger or the nail is gently insinuated. The protruded parts, if voluminous, are held down by an assistant; and along the forepart of the finger is passed a probe-pointed, narrow, and slightly curved knife. In carrying this upwards, the blade is placed flat on the finger, and its point, and no more, is passed through the contracted part; its edge is then turned forwards, its back resting on the finger; and by raising the handle gently, a slight incision is made into the more resisting fibres, in the direction of the mesial line. The instrument is withdrawn with the same caution as in its introduction. The finger now enters easily, and by raising it gently and repeatedly the parts are dilated. It is then passed upwards to the site of the internal ring: and if this be found narrow and contracted, the edge of the knife to be directed against it in a similar way, and dilatation to a sufficient extent effected. Now reduction is to be commenced, and in doing so the same precautions are to be observed as in the employment of the taxis. The hernial sac ought in the first place to be fixed by the fingers of the assistant placed in the bottom of it, so that it may be prevented from sliding up along with the contents. A neglect of this rule is often observed to lead to much embarrassment. The parts seem to have passed back into the general cavity; but on withdrawing the pressure they fall down again from the canal, along with the sac which had slipped up so far with them. In general, the omentum, if any, is put back first, and then the bowel; but this must depend on the relative quantity of the parts, and other circumstances. With the right hand the bowel is to be compressed as uniformly as possible; and, if at all obstinate, its reduction may perhaps be accelerated by pulling down a small portion at the neck, so as to facilitate the return of the fecal contents. By gentle pressure with the forefingers one portion is put back after another: it is wrong to attempt sudden and entire reduction; it should be gradual and successive. In many cases, from adhesion, or from the bulk and nature of the hernia, the parts, though sound, cannot or ought not to be reduced; a portion may be got back, but part requires to remain. This can often be ascertained beforehand by properly conducted and previous inquiry into the history of the case, as to the duration of the disease, and the period at which the whole tumour could be made to disappear. In such cases, the stricture should always be freely relieved. When the bowel is mortified, and its contents effused into the sac, care is to be taken not to detach or disturb the adhesions at the neck, and the bowel should be opened so as to allow of free discharge. When the bowel or omentum are comparatively sound, though irreducible, the surgeon must rest contented with relieving the stricture; then cover the parts with the integuments, and promote union of the wound. If it be considered necessary to remove condensed and tuberculated omentum, it is cut off, and separate ligatures of fine thread are applied to every bleeding vessel on the cut surface; the whole mass is not to be included in one noose, as was formerly the practice.

In the operation for femoral hernia, the position and preliminaries are the same as for inguinal. A longitudinal incision is made from above the margin of Poupart’s ligament to a little below the middle and most prominent part of the tumour. This is crossed by another at its lower extremity, the whole resembling in figure the letter T inverted; and the two flaps so marked out, are reflected. Sometimes a single incision, from above the neck of the tumour to the lower border of it, is sufficient to afford room for the after proceedings. For some years past I have performed an incision along the course of the ligament of Poupart, with another falling from it over the body of the tumour like the letter T, with the transverse part a little awry. In cases of very large femoral hernia, such as that seen on the next page, the incisions, as in the large inguinal tumour, must be made over the situation of the femoral ring, and to a limited extent. In this case

the symptoms had existed for eight days, and had been latterly very urgent, there being profuse feculent vomiting, and great depression of the powers of life. There was a large mass of bowel protruded: this was all returned, and the patient, though well advanced in life, made a rapid recovery. A cast was obtained after her death, which happened several years afterwards. It is seldom indeed that femoral hernia attains such a size. I have seen it in the male, however, nearly one half the size of the swelling here shown. The tumour is often not larger than a walnut, seldom exceeding the size of a small apple. One layer is found covering the sac, furnished by the strong and dense cellular tissue which occupies the space under the crural arch and falciform process of the fascia lata: it is generally denominated the fascia propria, and has been described improperly, it would appear, as the sheath of the femoral bloodvessels; at the lower part of the tumour it is generally wanting. It is carefully divided, so as to expose the sac. This not unfrequently is thickened very considerably, a quantity of dense fatty matter being intimately incorporated with it; but in general it is thin, and appears of a dark colour, in consequence of the bowel and effused bloody serum being seen through it. It is opened with great caution, part of it being raised and touched with the edge of the knife held horizontally, or nearly so. The aperture, thus formed, is enlarged by means of the probe-pointed knife, which is carried upwards along the forefinger of the left hand. Some recommend that the sac should be left undivided, and that the stricture should be relieved by passing the knife on the outside; others, that only the neck of the sac should remain entire, and the stricture be attacked also on the outside of the peritoneum. But this appears an unnecessary and unprofitable precaution. The extreme difficulty of returning the sac is now well known and generally acknowledged; indeed, reduction of it, whether opened or not, is practicable only in recent cases. Its neck, besides, is firmly constricted; and the bowel may and will remain strangulated when returned along with its sac, for the peritoneum long retains the contraction at its strictured point. The stricture cannot be well relieved unless the neck of the sac is cut along with the resisting fibres exterior to it. After the sac has been opened, the forefinger of the left hand is passed up to the crural ring; and it should be recollected that this opening is very small, even in most cases in which a hernia of ordinary size has existed for some time. It is capable of great dilatation, gradual however, so that, in very old and large ruptures, it may admit two or three fingers easily. But in general only the nail of the finger can be insinuated into it; and this is a better and safer conductor for the knife than a grooved director. The edge of the stricture is felt very sharp; the point of the finger is turned towards the pubes, and along it a narrow, blunt-pointed, curved bistoury is passed in close contact, and with the edge towards the pubes; its mere point is pushed beyond, and then the position of the blade is changed: its back is turned upon the finger. This slight motion is of itself often sufficient to relieve the constriction on the protruded parts, and permit their reduction; if not, a few more fibres are cut by raising the handle of the knife gently from the palm of the hand. The direction of this incision is towards the tuberosity of the pubes, inwards and forwards. Thus only the crescentic portion of the crural arch is cut; and the division of this produces sufficient relaxation of the neighbouring parts. There is danger in cutting directly forwards, particularly in the male, at least if the incision be made to any considerable extent; there is a risk of wounding the spermatic chord, and the obturator artery has also been met with in a few instances coursing round the neck of the sac. This distribution of the artery, however, is rare, and can occur only when the epigastric and obturator arise by a long common trunk, and even then it may not encircle the neck of a hernia, as I have witnessed. Occasionally a vessel of considerable size passes round the opening, connecting the epigastric with the obturator, when these arteries follow their usual course; and this also may surround the neck of the sac. If vessels should exist in this situation in a person the subject of operation, as has not happened so far as I know, they would be felt by the finger used to conduct the knife. And the bistoury should never be passed—for there is no necessity for it—through the opening so far as to meet with a vessel, even if awkwardly placed. The danger of cutting forward and to any extent has already been spoken of; such incision can answer no good purpose. The stricture is not in Poupart’s ligament—though at one time it was proposed to cut this through without interfering with the tumour at all—but in the crural arch underneath, and in a manner independent of the strong tendinous chord and expansion. The crural arch is formed by the junction of the fasciæ of the thigh and abdomen, superficial and deep. It is inserted into the linea ileo-pectinea, where the tendon of the external oblique has no connection, and is strengthened by fibres from the internal oblique, transverse, and recti muscles. The crural aperture formed by this arch is relaxed by flexion and inversion of the thigh, and by relaxation of the abdominal parietes. And this fact requires to be attended to, after operation as well as during the taxis, so as to facilitate replacement of the protruded parts.

The same attention to the state of the parts in judging of the propriety or not of reduction after operation, and the same after treatment, both general and local, is requisite in crural hernia as in inguinal. When the parts are reduced, the edges of the wound are brought together by means of a few stitches; a graduated compress, of proper dimensions, is applied, and retained by a spica bandage. If this is neglected, there is a risk of the parts again descending. Afterwards large mild enemata are to be administered, and, after some hours, purgatives, so as to procure copious and free evacuation of the bowels. In many cases after reduction, the bowels cannot by any means be got to act downwards. This seems sometimes to arise from a sort of paralytic state of the fibres of the part which has been extruded and

compressed. Again, it often arises from an indentation of the coats of the bowel at the point where they have been tightly embraced and compressed by the sharp edge of the opening, as here represented. The engorged and dark state of the upper portion of bowel contrasts well with the lower, which is generally empty, contracted, and pale. If the stomach continue unsettled, a sinapism may be applied to the epigastrium, or solid opium exhibited. Subsequently it may be necessary to bleed locally, or generally, or both; in other cases the strength from the first requires support. After cicatrisation, a well adapted truss must be constantly worn.

Umbilical hernia is generally congenital. The tendinous parietes are often deficient to a great extent, and there is consequently much fulness along the umbilical chord. The plan of embracing such tumours in children by ligature, as at one time extensively practised, is now abandoned, there being much risk of peritoneal inflammation and fatal issue. The surgeon is now content with reducing the hernia, and applying a truss, to prevent displacement, as in other forms of protrusion; and if this be done in early life, and the apparatus carefully worn, the opening contracts, and the patient may ultimately be cured. The tumour may become strangulated, though rarely in the adult; it is generally large, and almost solely occurs in females. The sac has no covering but the skin and cellular tissue and fatty matter. A small incision is made through the sac and its investments, either on one side of the tumour, or in the mesial line at its lower aspect. The stricture is then divided with care, the parts reduced, the wound approximated, and a compress applied. Opening the tumour throughout its whole extent is hazardous and unnecessary. The same remarks apply to the proceedings in cases of ventral hernia. In corpulent females the tumour is sometimes scarcely prominent, and is only discovered as a flattened cake through the fatty matter.

The contents of hernia are often in a very bad state, either dark-coloured throughout, or studded with dark tender spots. Lymph is often effused all over the parts, gluing them to one another, and to the sac. This effusion, which generally takes place to the greatest extent at the neck of the sac, is a wise provision made by nature against the accidents of the disease; inasmuch as a barrier is thereby formed between the cavity of the abdomen and the extruded parts, preventing, in a great measure, the destruction of the latter from affecting the abdominal viscera. For example, a portion of protruded intestine sloughs, the feculent matter is effused, and, had not this adhesion to the neck existed, the gut might have slipped back into the abdomen, its contents would have escaped there, and a fatal result would have been the inevitable consequence. Still, notwithstanding the salutary effusion, the bowel may ulcerate at its upper part, and, giving way within the belly, produce rapid death. The bowel, where embraced by the stricture, is contracted and thickened, and dilated above. At the lower part of this dilatation the coats are apt to give way by ulceration, even after incision of the constricting parts and reduction. The contraction does not disappear quickly. In some cases it continues to such an extent as to keep up obstructions to the fecal matter, and cause a fatal issue from this cause alone, as noticed above.

Often, on opening the sac, in long neglected cases, a discharge takes place of fetid air and thin feculent matter, the bowel has mortified either entirely or in patches; in the latter case, presenting the appearance of having been perforated at various points. Few constitutions can bear up under such mischief. In some, if an opening be not made, the integuments slough, and the patient, rallying after discharge from the bowel takes place, recovers after losing a portion of integument, of intestine, and perhaps of omentum. In others, and they constitute the majority, the system sinks, before discharge from the bowel is effected, by sloughing of the external parts.

The surgeon is called on to operate in the worst possible circumstances, provided the patient is not in articulo mortis. Even after many days of feculent vomiting the bowels may be found tolerably healthy. The sac must be opened carefully, and the stricture is to be relieved without disturbing the adhesions that have formed. The bowel, when dead, or evidently gangrenous, is to be opened, and the discharge of feces by the wound promoted. If returned into the abdomen, the sloughs will separate, in all probability, and feculent effusion take place, causing death in a very few hours. Sometimes the patient lingers longer than could be expected, and I have known a female survive upwards of a hundred hours after the occurrence of effusion into the abdomen, from the giving way of an ulcer in the stomach. The dressing should be light, and the patient’s strength must be supported in every way, by the mouth, and by the anus when the injured part is high in the canal. The separation of the sloughs is to be encouraged. The extent of sloughing need not dishearten the surgeon, for large portions of bowel, several feet in length, have mortified, and the patients recovered, with artificial anus, either temporary or for life.

In artificial anus, when this has followed upon destruction of the bowel to a considerable extent, the intestine has contracted firm adhesion to the hernial sac at the opening in the abdominal parietes; through the opening in the bowel exterior to this the feculent matter is discharged externally, and by the adhesion is prevented from being effused into the abdominal cavity. The protruded bowel in which the sphacelation has occurred may be said to be thereby divided into an upper and an under portion,—one, the upper, discharging, the other, collapsed and empty; these lie parallel to each other, in close contact, and usually adhering, from the abdominal or crural ring downwards, to each other, and to the hernial sac. The hernial sac seldom sloughs entirely; in almost every case its neck remains sound; to this remaining part the intestine adheres. The deficiency in the integuments and cellular tissue, through which the feculent matter escapes, gradually contracts, and the aperture in that portion of the hernial sac which is exterior to the intestine also diminishes; but at the same time dilatation takes place in the immediate vicinity of the intestinal orifices, so that a funnel-like cavity is formed for the evacuation of feces, extending from the opening in the bowel to the opening in the skin—its narrowest part being at the latter situation, its most capacious surrounding the intestine. The cellular tissue intermediate between the integument and hernial sac becomes condensed, and forms a membranous lining. By this cavity an imperfect communication is established between the two portions of bowel, part of the feculent matter returning through the lower intestinal orifice, and part escaping externally. But this communication must be indeed very imperfect at first, since the two portions of bowel lie parallel to each other, and their coalescing sides form an acute angular projection into this funnel-shaped cavity. The lower portion is necessarily much diminished in calibre, being in a great measure unaccustomed to the usual distension, and its collapsed orifice is retracted a little higher than that of the superior. On account of these circumstances feculent matter cannot pass straight onwards from one portion of bowel to the other, but must first traverse the funnel-shaped cavity; and even then it is but a small quantity that reaches the rectum. Indeed, in most cases of artificial anus, nothing but occasional flatus passes by the original outlet for weeks or months. After some time the bowel retracts, but cannot leave the adhesion in the groin: by this retraction the orifices may be brought in a more direct line with each other, and the natural passage of the feces be somewhat assisted.

When one or more slight patches of discoloration are observed after division of the sac, it may be returned, it being most probable that the parts will recover after removal of the stricture. When any portion has given way, of course no one can contemplate reduction; and when the whole calibre has sloughed it is absurd to attempt separation of the adhesions which must exist, dividing the external from the internal parts.

In mortification of a protruded knuckle, or part only of the calibre of bowel, the symptoms are at first severe. These are vomiting, pain, and symptoms of enteritis; perhaps the bowels are obstructed for some time, but evacuation again takes place, as happened in the following remarkable and instructive case. A gentleman, nearly eighty years of age, was, during the action of medicine, suddenly seized with pain in the groin. A very small tumour was observed— he became sick—and when I visited him for the first time two days after, he had no further evacuations from the bowels, he vomited constantly bilious fetid matter, and he began to complain of pain in the abdomen. Pressure was kept upon the tumour, which protruded at the crural aperture, for some time, with the effect of diminishing its size very considerably. On returning in a couple of hours with Sir B. Brodie, with the intention of cutting down upon the swelling, the bowels had been freely relieved, the vomiting had entirely ceased, and there was not the slightest vestige of tumour to be perceived or felt, on the most attentive examination. The patient had a good night, but in the morning had a recurrence of the symptoms: these continued, and a fatal termination shortly occurred; still no tumour could be detected before or after death. It was supposed that the obstruction might have been caused by a continuance of the constriction of the bowel, where it had been nipped by the stricture. On a post-mortem examination, there was found an exceedingly small portion of the coat of the bowel still entangled

in the crural ring, whilst a larger portion, which bore marks of having been protruded, was thus entangled, and confined to the spot. The bowel, though not completely obstructed, was narrowed by the confinement of part of its parietes.

Abscess often occurs externally to a small swelling of this nature, and on the giving way of the integument, matter, flatus, and thin feces are discharged. A fecal fistula remains for some time; but, by the aid of lymph and granulations, the breach in the parietes of the bowel is repaired gradually, the feces resume their natural course, and the external opening heals.

When the whole calibre has sloughed, and even when a large extent of bowel has come away, and there is still a chance of the patient recovering from the artificial anus by natural means, after the lapse of many months. As already remarked, the intestinal orifices retract, and come more into a straight line. A mucous discharge occurs from the lower bowels along with the passage of flatus, and at last part of the feces is voided by the rectum. The discharge from the external opening diminishes, and ultimately ceases, perhaps only a minute fistula remaining, through which a few drops of fluid, sometimes feculent, sometimes limpid, may occasionally escape. The funnel-shaped cavity previously contracts into a narrow fistula. This desirable result may be assisted and hastened by gentle pressure; and, after the feculent discharge has nearly ceased from the fistulous opening, the healing of this may be accelerated by the cautery lightly applied. It has been proposed to destroy the projecting septum between the two portions of bowel, either by ligature or by the pressure of forceps; but this should not be attempted unless nature seems unable to effect a cure. The former method consists in including a considerable part of the septum in ligature, so as to induce condensation of the parts by effusion of lymph, and destruction of the projecting portion. This has not been found very successful. The application of forceps presents a more rational expectation of cure. The external opening is dilated, and the situation of the septum ascertained. One blade of metallic forceps, with blunt serrated edges,—Dupuytren’s,—is passed into the one intestinal orifice, and the other into the opposite; the handles of the instrument are then approximated, locked, and fastened with a screw, and by means of the last-mentioned part of the apparatus the degree of pressure is regulated. Pain of the abdomen, furred tongue, loss of appetite, sickness, vomiting, and constitutional irritation, generally follow this proceeding, but gradually subside on the employment of enemata and fomentations, and on lessening the pressure of the forceps. The septum cannot long withstand the continued compression, and by its destruction the chance of cure is greatly augmented. The proceeding is, besides, not so dangerous as might at first be supposed; for effusion of lymph takes place to a considerable extent above the part grasped by the forceps, gluing the portions of bowel firmly to each other, and forming a new barrier against any of the feculent matter escaping inwardly. Attempts may be made to repair the loss of substance in the skin by paring the edges of the opening, and affixing a flap taken from the neighbourhood.[45]

There is a greater chance of recovery from the inconvenience of artificial anus after hernia than after wounds. If the opening in the bowel be near the stomach, the patient will die from inanition. When it is lower in the intestinal tube, nutrition is more perfect, and the patient can be further supported by nutritive enemata. When no natural cure is likely to take place, the inconvenience will be palliated by a truss with a soil pad being worn, so as to retain the feces till a favourable opportunity occurs for evacuation; or a soft plug of lint may be inserted into the aperture, and retained by a compress and roller. Prolapsus of the mucous membrane of the gut sometimes takes place through the artificial anus, and is reduced with difficulty. The use of a truss or tent, already mentioned, will tend to prevent the occurrence. Great attention to cleanliness is required when the opening cannot be closed.

Operations for other kinds of hernia, if discovered during life, are to be conducted on similar principles with those for inguinal and crural. The surgeon must be guided by his anatomical knowledge. No positive rules can be given.

In Ascites, or accumulation of fluid in the peritoneal cavity, the surgeon is not unfrequently called upon to relieve the patient, when the abdominal parietes are much distended, and the functions of the viscera of the abdomen and thorax interrupted. He must, however, exercise his own judgment in regard to the case, and convince himself of the propriety of operating. He must examine into the symptoms, and ascertain that the tumour is really caused by accumulation of fluid in the bag of the peritoneum. In ascites, the abdomen has swelled slowly and uniformly, and distinct fluctuation is felt when the hand is placed on one side of the swelling, and gentle tapping made at the other. There is considerable difficulty of breathing, uneasiness in the abdomen, usually increased by pressure, thirst, and scanty secretion of urine. It ought to be remembered that other affections have been confounded with ascites, and lamentable operative mistakes committed in consequence. Trocars have been thrust into the belly for tympanitis, either of the bowels or of the peritoneum—for solid tumours of the viscera—for enlargement of the ovaria.

As already hinted, the operation of tapping the abdomen is to be undertaken only when the distention is very great, when the functions of the thoracic and abdominal viscera are interfered with, and when diuretics, and other means of getting rid of the fluid, have failed to diminish the accumulation. The trocar employed is either flat, with a spring steel canula, or round; when the latter is used, and the abdominal parietes are not very tense, a small incision is first made with a lancet or bistoury; a large trocar with blunted edges and point can then be readily and safely introduced; the flat one enters easily, and requires no previous wound, but does not permit so rapid and free a flow. The point usually chosen for the puncture is either in the linea alba, a little below the umbilicus, the bladder being previously emptied,—a precaution which should always be attended to, though in general there is little danger of wounding this organ—or midway betwixt the superior anterior spinous process of the ilium and the umbilicus, with the view of penetrating the parietes in the linea semilunaris. The latter situation, however, can seldom be obtained with accuracy, for the parietes yield irregularly. Little bleeding follows the puncture at either point; but the risk of hemorrhage is greater at the latter, for branches of the circumflex artery may be wounded. More serious bleeding is liable to occur, from the veins ramifying on the abdominal viscera giving way, on removal of their support, as the serum flows off. Fainting, also, may take place from accumulation in the branches of the vena portarum, unless the fluid is withdrawn slowly, and the precaution adopted of supporting the parietes with a broad band both during and after evacuation. Bandages are made for this purpose, with tapes and straps attached, and are well fitted for it. Three or four yards of flannel, however, with each end split, are equally effectual, and can always be readily obtained—a consideration of consequence in the choice of all apparatus. After the band has been applied, a person is placed on each side to tighten it gradually by steady pulling at the ends, which are carefully crossed behind. An opening is made in the cloth, opposite to where it is proposed to puncture, and the operation is then proceeded in. Sometimes the flow is impeded by the omentum or a fold of bowel falling forward on the canula, and closing or diminishing the opening; this is remedied by passing a tube along the canula, closed at the extremity, but perforated at the sides near it, and about half an inch longer than the canula. After the cavity has been emptied, the patient is placed recumbent, and a long broad flannel bandage applied over the whole abdomen, and retained, so as to prevent shifting, by straps passed over the shoulders and under the perineum.

Collections occur in the ovaria. The fluid is generally glairy, sometimes thick and gelatinous, often turbid and dark coloured. Not unfrequently the main cyst is subdivided, either by membranous septa, or by an aggregation of smaller cysts of the nature of hydatids. The swelling is at first on one side, and gradually rises out of the pelvis; often it remains long moveable; it increases, becomes more fixed, and ultimately fills the abdomen, displacing the viscera, and giving rise to feelings of much uneasiness, deformity, and loss of health. The cyst is generally thick; sometimes it is thin at one or more points, and this may give way, causing effusion of the contents into the peritoneal sac. Fluctuation is perceptible in many cases; in others it is obscured by the thickness of the cyst and viscidity of its contents. Many such swellings may be punctured both with advantage and with safety, but generally the tapping requires frequent repetition. Some patients require tapping, merely as a mean of improving the figure and relieving uneasy feelings, once, twice, or thrice a year; their existence is not much embittered or abridged by the disease. A large round trocar is necessary for the purpose; and the puncture is made at the softest and most prominent point of the tumour, a small incision through the integument being premised.

The ovaria become enlarged by degeneration of their structure and the addition of solid matter in great abundance. The consistence and structure of such tumours are very various; they are sometimes, though rarely, medullary, often fibrous, with or without cysts, sometimes melanotic. In the majority there are cysts, varying in size, number, and contents; sometimes the bag contains hydatids, or it is filled with curdy matter, sometimes with glairy colourless fluid, sometimes with a turbid and flaky serum, sometimes with blood; and in them, as well as in the enlargement from accumulated fluid, though perhaps more rarely, are occasionally found teeth, hair, and membranous looking matter; some are intermixed with bone, cartilage, and fat.

The situation and attachments of such tumours cannot be correctly ascertained by examination during life, far less can their internal structure and dispositions be arrived at. Indeed an accurate diagnosis is exceedingly difficult, if not impossible. Innumerable mistakes have been made, which have led to most unjustifiable proceedings. In one case, the abdomen was, after two or three dry tappings, opened by an incision from the ensiform cartilage to the pubes; the viscera were turned over and over, but no tumour could be discovered. The woman was sewed up, and did not die. The following was a still more complete failure in diagnosis. In a case of large tumour of the belly, many persons accustomed to manipulate abdominal swellings considered that extra-uterine conception had taken place; and that the child had come to maturity and perished. The history of the case countenanced the supposition; the symptoms had been such as indicate impregnation. The woman, to avoid exposure, went to a distance to be relieved of her burden, which was becoming more and more troublesome and bulky. The usual period passed over. It was thought that the head and thorax of an infant could then be felt readily through the parietes, and perhaps some one might have been found heroic enough to have divided them and explored the tumour. The young woman, however, was in the last stage of phthisis, and soon died. A wonderfully tuberculated omentum, a very small portion of which is here represented, filled the peritoneal cavity; the uterus and its appendages were quite healthy.

Operation has also been proposed, when, on dissection, the liver was found to compose the abdominal swelling. Such cases, a long list of which might be given, render the prudent surgeon very cautious in his diagnosis of abdominal tumours, and chary of operative interference with them. The abdomen has been opened, as already stated, and the result has been such as to render the perpetrator indictable for culpable homicide, and to qualify him for such punishment as his rash and reckless conduct richly deserved. A less severe censure might have sufficed, had not the example been followed by similar proceedings, and equally direful results; and these have been such as to render any condemnatory remarks not only justifiable but absolutely necessary. A great many unfortunate women have, I am afraid, been sacrificed to a desire for false reputation. The attempts to remove abdominal tumours by incision of the parietes were some time ago very numerous; and, as might have been expected, the issues were highly unsatisfactory to those concerned. Such doings, however, were recorded in print, represented in plates, and moreover puffed and placarded ad nauseam. The majority of those who were thus “dissected, to see what part was disaffected,” perished within forty-eight hours. One woman survived for some time, after having been subjected to this operation, improperly so termed. In her there was a tumour, but of such a size, and so connected, that it could not be removed. A second survived the extirpation of one ovarium; and the other, also diseased, was left for a further exhibition of daring intrepidity. It is not easy to conceive how the proposal could have been seriously entertained by any sane individual, far less put in practice and persevered in, when disaster after disaster crowned every attempt. It is my opinion, and I believe that I express the sentiments of a very large portion of the profession, that the repetition of any such incisions and gropings would be unpardonable.—1. On account of the difficulty, nay, impossibility, of forming a correct diagnosis; of ascertaining with certainty what organ is involved; of ascertaining the structure and disposition of the tumour, if any, and to what parts it is adherent. 2. Because the ovarian disease, in general, even though extensive, does not threaten imminently a fatal termination, being slow in its progress, and the greater number of the swellings being not of a malignant nature. The solid tumours are sometimes of a bad kind, as already stated; but enlargement by fluid is much more frequent in the ovaria than that by solid and new matter. 3. If the tumour be malignant, it will be impossible to ascertain to what extent the parts are involved by the diseased action, or whether the lymphatics are affected or not. There is a strong probability of the lymphatic system being involved, even at a very early period; and then the extirpation of the tumour—supposing the mass to be so situated as to admit of removal without difficulty or danger—cannot be attended with any advantage; in every point of view, therefore, interference is unadvisable. 4. The operative attempt is attended with imminent danger. There is almost a certainty of the patient being almost instantly destroyed by it, as shown by the sad experience of the past. “We are not the arbiters of life and death of those who apply to us for relief. If people die in consequence of disease, it cannot be helped. They submit to it because they know it is inevitable. But we had better refrain from making such experiments as may probably destroy them, and bring disgrace upon the profession.”

Bruises of the abdomen are apt to be followed by inflammation of the contained parts, particularly of the serous membrane. Occasionally lacerations of the viscera, both solid and floating, but more frequently of the former, are produced by bruising or squeezing of the abdomen, as by a blow, or by a heavy body passing over; they may also follow a violent concussion of the parts by falling from a height. The liver is the organ most frequently torn, and death is commonly the result, rapid, and principally from hemorrhage. The laceration is generally on the convex surface; extravasation takes place under the peritoneal covering; or this is torn, and the effusion is into the abdominal cavity. When the quantity of blood is not so great as to cause speedy dissolution, the patient may survive for some time, and even ultimately recover. Reaction is slow, the patient continuing a long time pale, exhausted, and almost pulseless; there is tenderness in the hypogastric region, with swelling. The spleen is liable to similar injury, and pours out a large quantity of blood.

The gall-bladder has sometimes been torn, as also portions of the small intestines, by a blow or kick, or by a heavy body passing over the abdomen, as the wheel of a loaded wagon. The escape of the contents is followed by sickness, rigour, quick, weak, and indistinct pulse, most excruciating pain, a sense of heat diffused all over the abdomen, and rapid sinking of the powers of life; a fatal termination generally occurs within twelve hours. The same train of symptoms supervene when the contents of the intestinal canal have been effused into the peritoneal cavity, through an opening in the stomach or bowel, caused either by slow destruction of the coats, the peritoneum giving way last, or by a rapid ulceration or sloughing process, as in hernia. The patient may live in agony for a day or two, but death generally takes place much within twenty-four hours. The same may be said of the rupture of the bladder, from external violence, with effusion of urine into the peritoneal sac. No treatment is of any avail; venesection hastens the sinking. Fomentation over the abdomen, and sedatives either by the mouth or by the anus, soothe the patient, and render his last moments more calm.

Penetrating wounds of the peritoneal cavity, if they reach the solid viscera and large vessels connected with them, are attended with effusion of blood externally and internally, in quantities proportioned to the size of the external aperture, the importance of the vessels concerned, and the vascularity of the part. The patient may perish from the bleeding, either instantly or after some time; or inflammation and its consequences supervene in the violent form, and destroy him at a more remote period. The mere opening of the peritoneal cavity, and to a very slight extent, without the slightest injury of the contained parts, is often attended with a great shock to the system, and is followed by inflammatory action, which may run on to a fatal issue, in spite of the most active and judicious management. The inflammatory symptoms are to be combated by free abstraction of blood; in short, the utmost endeavours must be made to keep the action within bounds. When the intestines are wounded, the injured part may protrude; or the relative size of the openings through the parietes and bowel may be such, that the intestinal contents do not escape into the peritoneal bag. A natural cure sometimes takes place by adhesion of the surface of the bowel to the lining of the parietes round the wound, feculent matter continuing to be discharged externally; after a time the opening may contract, and the discharge diminish and ultimately cease; or an artificial anus may be permanently established, and this is not so easily cured as that following upon hernia. Wounds of the intestines, whether transverse or longitudinal, attended with feculent escape into the peritoneal cavity, are not uniformly fatal. Effusion of lymph takes place around, gluing the wounded bowel to the peritoneal surface of a neighbouring fold, or forming a sort of pouch within which the extravasation is limited. The treatment consists in absolute rest, and most rigid antiphlogistic regimen; manual interference with the wounded part is not generally advisable.[46]

Lumbar Abscess is generally chronic; the collection of matter is gradual and slow. Sometimes it is acute, and rather rapid in its appearance. It may originate in the sheath either of the psoas or of the iliacus muscle; more frequently it seems to form behind these, and is connected with diseased bone. The precursory symptoms are often not particularly attended to; these are rigors and pain of the loins. As the disease advances, the patient feels great pain in the erect position, and in general the pain is aggravated by extending the thigh. Thickening and slight glandular enlargement takes place in the groin; there is an evident fulness there; and then swelling appears on the inner side of the femoral vessels, beneath the pubal portion of the fascia lata. This swelling is more prominent in the erect position, and is also increased by exertion of the abdominal muscles; an impulse is given to it on coughing. As it advances, and comes more to the surface, fluctuation is perceived. This is the most common site in which the abscess presents itself; but it is not unfrequently met with on the outside of the vessels, either lower or higher in the thigh, above Poupart’s ligament, in the loins over the crest of the ilium, and occasionally the matter is insinuated under the pelvic fascia and appears by the side of the anus. Large and neglected collections may work their way to the surface in two or three of these situations at the same time.

The disease is often attributable to a sprain or wrench of the loins, or to exposure to cold and over-fatigue. Occasionally the mischief is confined entirely to the soft parts; the vertebræ, a portion of the os innominatum, or the sacrum, may be denuded and of irregular surface, but this is evidently the result of the pressure of the abscess. A striking example of this, and of the extensive destruction of parts which this affection sometimes produces, may be shortly stated.—A very large lumbar abscess formed within a few weeks, in consequence of great and continued fatigue and exposure to bad weather. At first it had been trifled with. At last it was opened in the usual situation in the thigh, and a vast quantity of matter evacuated. Thirty-six hours afterwards, the patient was suddenly suffocated by a flow of purulent matter into and through the air passages. On dissection, the cavity of the abscess was found to be immense, opening through the diaphragm into the lung which was adherent, and communicating with the bronchi. The forepart of the lumbar vertebræ was exposed, and in some parts stripped of the theca; but there were no cavities in the bone, and no disease of the interposed cartilages. Such cases are now and then met with, of abscess in the loins not originating in any vice either of the bones or of any other part of the apparatus of the spinal column. Most frequently, however, the collections have their foundation in ulceration of the bodies of the vertebræ. The patient has had tenderness in the part, weakness of the back and of the lower limbs, and increase of pain on pressing or striking some particular spinous processes—perhaps slight excurvation. Then pain in extending the thigh supervenes, followed by swelling and other signs of abscess. This is preceded generally by deposit of tubercular matter in their cancellated texture. Sometimes the disease seems to originate in the ligaments and articulating surfaces; occasionally portions of the bone perish,

and are found lying in the cavity of the abscess, as seen in this specimen, taken from a young subject. When the bodies of the vertebræ are attacked by ulcerative absorption, and sometimes the disease is very extensive, involving perhaps four, five, or six of the bones, there is more or less curvature of the spine outwardly—excurvation. If the disease affects one or two bones, and their bodies are almost destroyed, then the projection is sharp and angular. When the disease is more extensive the curve is greater, and more gradual ulceration sometimes exists to a considerable extent in one articulation, without change of form externally in the spinal column, and sometimes without any great collection of pus. When curvature commences there is very generally more or less weakness of the limbs, though curvature, whether from ulceration or interstitial absorption, is by no means of necessity attended by any degree of paralysis. The power of motion of parts supplied by nerves in the neighbourhood of disease is diminished earlier in general than the sensation, in consequence, possibly, of the mischief commencing in the anterior part of the bodies of the vertebræ. It is wonderful to what extent disease may extend in the vertebral column, without much impairment of the functions of the spinal chord, and how perfectly the functions are restored in cases where it has suffered. The lumbar vertebræ are those most frequently affected, but the ulceration may also be either in the dorsal region or in the pelvis. Disease of the last lumbar vertebra at its connection with the sacrum, or disease of the sacrum itself, is attended with abscess around, which descends into the pelvis, displacing the bowel, and appearing by the side of the buttock.

Such abscesses may have been allowed to come to the surface, and to discharge their contents spontaneously; or they may have been at a late period opened either at one point or at several. In these circumstances, the discharge is generally profuse, long-continued, and attended with exhaustion and hectic, gradually but surely destroying the patient. But, by good management, a perfect and permanent recovery may in many cases be obtained. When the vertebræ are affected, absolute rest must be enjoined and enforced; and a drain is to be established by the sides of the spinous processes, either by moxa, potass, or seton—it is immaterial which. The discharge is kept up by occasionally dressing the issue for a few hours with an acrid ointment, so as to reproduce a slough. When the abscess begins to present, it should be opened as early as possible, and a free exit allowed to the matter; the discharge should be at no time confined. The opening of the cavity, and again shutting it up, however carefully conducted, is in almost every instance followed by alarming and hazardous results. Rapid accumulation of putrid and bloody matter takes place, and air is extricated within the cavity; the vessels of the cyst, being unsupported, part with their contents; irritative fever is lighted up, with rapid pulse, anxious countenance, and delirium. These symptoms are relieved only by immediate evacuation of the fluid. Some slight constitutional disturbance follows the making of a free opening, but quickly subsides; then the discharge improves in quality, becomes more pure and unmixed, diminishes in quantity, and gradually ceases. During the discharge the strength requires support; and the attention to the original mischief must not be neglected or intermitted.

Spina Bifida is a congenital fluctuating tumour, with deficiency of the subjacent vertebræ. It is usually situated in the lumbar region, sometimes in the dorsal, and often over the sacrum. The size of the swelling varies according to the age of the child, and the extent of deficiency in the parietes of the spinal canal. The spinous processes are either imperfect or altogether wanting, and over the space so formed the tumour is situated. Its contents are usually of a serous character, thin and colourless; sometimes they are turbid and flaky. The parietes seem to be a continuation, or protrusion, of the membranes of the spinal chord, thickened and somewhat altered in structure, and usually in close contact with and adherent to the integuments. By pressure the size of the tumour is diminished; but, if firm or long continued, unpleasant effects are apt to result. There is often debility of the lower limbs, and the disease is not unfrequently coexistent with hydrocephalus. Children with this affection seldom live more than a few years.

The application of gentle, uniform, and continued pressure affords support to the parts, and prevents increase of the tumour; and, under this palliative treatment, life may be both rendered more comfortable and prolonged. It has been proposed to combine continued pressure with occasional puncturing of the cyst by means of a fine needle, with the view of diminishing the tumour and ultimately obtaining entire obliteration of the cyst. The practice has been made trial of, and the result may warrant repetition; caution, however, is necessary, for the too free opening of the tumour is often followed by a rapidly fatal issue. A case occurred to me not long since, in which the tumour, of large size, was situated over the sacrum. The fluid was evacuated by a small trocar and canula, the parietes shrank, and a very satisfactory cure resulted.