Elements of Surgery

by Robert Liston

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.