Chapter XXIII: Part 23

Leeching is of little use in mammary swelling during lactation; cold and evaporating lotions seem to do harm by producing determination from the surface to the deeper parts. The gland is to be kept as free from secretion as possible, and supported by a handkerchief tied round the neck; moderate diet should be enjoined, and laxatives given occasionally. Fomentations are beneficial at first, but are superseded by poultice when matter appears to have formed and to be making its way to the surface. Two or more openings are generally necessary, to afford free outlet to the matter; indeed, an incision is indicated wherever the integuments are elevated, thin, and shining. Afterwards poulticing is continued for some days, and succeeded by other suitable applications. The discharge seldom ceases, so long as the secretion of milk is encouraged.

Adolescent males are sometimes affected by troublesome fulness and uneasiness of the mammillæ. Little or no treatment is required, the inconvenience subsiding gradually and spontaneously.

Indolent enlargements of the mammary gland occur, though rarely. They sometimes attain an immense size; and are often attributable to the menstrual discharge having been inopportunely arrested. Such tumours have, from their great bulk, required extirpation.

Sarcomatous tumours of various kinds are met with, either in the cellular tissue under the mamma, or in the substance of the gland—tumours not of the gland, though in it. Such are generally traced to injury, as to a bruise by falling against the corner of a table or chair, an accidental push from the elbow of another, &c. Simple sarcoma is the most frequent formation; but I have encountered tumours, thus situated, of a worse nature—reproduced, though freely and fully removed; in fact, taken away along with the gland and neighbouring adipose substance.

The gland itself is most frequently affected by carcinoma. Sometimes it is attacked by, or involved in, medullary sarcoma; and bloody tumours are also met with. In some cases, the gland is enlarged and softened, and penetrated by cysts of greater or less size, and more or less numerous, containing a fluid either serous, albuminous, bloody, or thin and black.

The appearance and progress of carcinomatous and other tumours have been already described. The mamma is more frequently the seat of malignant disease than any other gland; it is frequently excited, and much exposed to injury. Often the induration following abscess remains stationary for several years, and at length takes on a new action, forms morbid deposit, and is of rapid growth. The disease seldom occurs in young subjects; though I have met with several well-marked cases under thirty. Before that time of life, the tumour is generally of a strumous nature, and this should not be confounded with the malignant; for the one is remediable under the influence of constitutional means, the other is not. Malignant disease is in most cases developed about the period when the menstrual discharge ceases; when the discharge is irregular previously to its entire cessation, the mamma is excited, and then hardness is perceptible. The disease also forms, though seldom, long after the “critical period,” but in such cases its progress is usually slow. It occurs, also, and not unfrequently, in those who have never had the mamma excited by lactation; the mammilla is also subject to malignant disease in males advanced in life.

When the malignant nature of the disease is recognised, the tumour should be extirpated without delay, before it has made much progress—before it has contracted extensive adhesions, or contaminated the lymphatics. The circumstances rendering interference unadvisable have been fully spoken of when treating of tumours generally. If the patient is a female, the period of the menstrual discharge, if still regular, must be attended to, and avoided; indeed this maxim should apply to every operation on the female. The most favourable time for operating is some days after the cessation. The position of the patient should be sitting, unless the dissection is expected to be tedious; but it ought not to be so,—the extirpation of glands, or the detachment of the tumour from parts to which it may have contracted firm adhesions, can alone cause delay; and when these circumstances exist, interference is not allowable. Any warrantable operation on the mamma can be completed in a very few minutes. Two elliptical incisions are made from the border of the pectoral muscle, in the direction of the fibres, embracing the nipple and any portion of the integument which may be adherent or altered. The surgeon need never hesitate to sacrifice the nipple, for in this disease it can be of no further use; besides the malignant action is apt to return in it when saved, it being almost always adherent to the tumour: it must be removed. The incisions are made quickly with either a scalpel, or a sharp-pointed and broad bistoury; the lower should be the first, that the flow of blood may not interfere with it and obscure its course. This is carried at once through the skin and subjacent adipose tissue, and then the upper is made rapidly, to get over the most painful part of the operation as soon as possible. The dissection is next proceeded in, from the axillary region forwards, and the tumour detached first on one side, and then on the other. A few strokes of the knife will separate the remaining cellular attachments to the fascia of the muscle, or of the fascia to the muscle. The surface of the wound and of the extirpated mass should be carefully examined, so that no part may remain whose structure is altered. The vessels are tied; and after oozing has ceased, if sufficient integument has been saved, the edges of the wound are put together and retained. The patient is placed in bed, with the head raised and the arm slung.

Operation is scarcely justifiable when it is evident that the absorbents are affected. Yet a small glandular tumour on the border of the axilla, without any enlargement more deeply seated, may be removed along with the mamma. With this view, the incisions should be made so as to include the tumour, and detach it previously to the mamma being interfered with. But when swelling has taken place deep in the axilla, it is impossible to ascertain its exact extent, and it may be considered very certain that a chain of altered and enlarged glands lie along the course of the axillary vessels. The whole of such a tumour cannot be taken away, and, in removing even the more prominent and accessible parts of it, there is great risk of wounding the axillary vein. This blunder I have seen committed more than once, and I have also seen the vein, the artery, and the majority of the nerves, all included in one ligature in order to stop the bleeding. I need scarcely add that the patients soon perished. When enlarged glands are perceptible above the clavicle, or in the intercostal spaces, the practitioner who would advise interference with the original tumour must be grossly ignorant, or very unprincipled.

After removal of the mamma for carcinoma, in favourable circumstances, some patients remain healthy. Those practitioners who do not recognise the malignant disease, and operate for every tumour, and at all ages, have boasted of great success. But it is not so with those of mature experience. The _disposition_ to malignant action often remains latent for many months, sometimes for many years, and at length becomes fully developed. The disease may return in the skin; the cicatrix hardens, ulceration occurs, and makes progress. Or tubercles form in the cellular tissue, enlarge, and involve the skin. Or the glands become tender and swell; and the swelling is often unattended with uneasiness. Œdema of the hand and forearm, to a great extent, may have existed for a considerable time, and on examination extensive glandular tumours are detected in the axilla and above the clavicle. These, perhaps, ulcerate; or cough and hectic cut off the patient. In short, permanent riddance from mammary carcinoma is scarcely to be expected by operation, or any other means.

Neither are operations for medullary and bloody tumours of the mamma more successful in their results; though I have certainly witnessed permanent cures under unpromising circumstances,—when the tumours were large, of long duration, and even ulcerated.

AFFECTIONS OF THE CHEST.

Inflammation of the pectoral serous tissue would come to be considered more properly in a work exclusively on the practice of physic; but the affection not unfrequently occurs in consequence of wounds or other external injuries, and its terminations must be shortly noticed.

Effusion of serum may take place into the cavities, attended with subsidence of the symptoms of pleuritis. In such circumstances, the lung collapses, either entirely, or still admits a small quantity of air; and, if the collection lodge for a considerable time, that side of the chest enlarges. When the cavity is not quite full, the fluid is heard to be troubled, and on motion of the trunk a sound of splashing is perceived. Part of the cavity may be occupied with air which has escaped from an opening in the lung; or halitus may be extricated from the accumulated secretion. There are other signs, sufficiently distinct, imparting a knowledge of such effusion. The previous history of the case leads to a shrewd suspicion. The chest is unnaturally immovable, as well as enlarged; the intercostal spaces are widened, and ultimately protuberant; there is dulness on percussion, and no respiratory murmur perceptible in those parts where there is fluid; the sounds are natural in that part of the lung which is permeable to air, and distended.

Suppuration often is the result of the incited action; and purulent matter forms in the cavity of the pleura, generally without breach of surface. The membrane is covered with lymph, more or less extensively organised. _Empyema_ is established. Suppuration may take place in the substance of the lungs, and from ulceration the matter may escape, in small quantity at a time, into the bronchial tubes, giving relief to the patient; or it may be poured in profusely and suddenly, so as to cause instant suffocation; or it may work its way into the cavity of the pleura, and occupy the same place as if it had been secreted by that membrane. Or, again, if the lung adhere to the costal pleura, the matter may approach the surface of the body, by the aid of interstitial absorption of the intervening parts, and the collection may then be opened, like a common superficial abscess, by division of the integuments only.

When the pleura is full, the chest enlarges, the integuments become œdematous; and if, from the preceding and collateral circumstances, no doubt exist of the presence of matter, paracentesis may be performed with a chance of relieving and saving the patient. The patient is placed horizontally, with the shoulders slightly elevated; and the affected side should be as dependent as possible, that he may be readily turned over on his face should the breathing become embarrassed. The position of the diaphragm, in regard to the inner surface of the false and lower true ribs, must be kept in view. When the distention is great, this important muscle is displaced; it is pushed downwards, carrying before it the viscera in the upper part of the abdomen; it is thus removed far from the place at which the incision is usually made. The point of election, as it is called, is between the fifth and sixth ribs, and midway between the sternum and the spine. An incision is made through the integuments, over the upper edge of the sixth rib, an inch and a half in extent; in this situation there is no risk of wounding the intercostal artery. If the operator intend to shut the cavity as soon as the fluid has been discharged, the integuments are drawn upwards previously to making the incision, in order that they may afterwards overlap the wound. A cautious opening is then made through the intercostal muscles, and the pleura punctured. This is immediately followed by forcible ejection of fluid. The wound of the pleura is then enlarged by a probe-pointed knife. The thrust of a trocar, or sharp-pointed bistoury, is here inadmissible, as in some cases the diaphragm, perhaps the liver or stomach, or even the lung, might be wounded. The fluid at first escapes rapidly; afterwards it is ejected chiefly during expiration. After its discharge, a tent is placed in the wound, over which a compress is put, and the chest is firmly bandaged. The closure cannot be maintained safely longer than twenty-four hours; the dressing must be undone, the tent removed, and the matter again allowed to flow. I would certainly not recommend any attempt to heal the wound by the first intention. In consequence of continued closure, the secretion soon becomes very profuse, mixed with blood, and of a putrid nature; irritative fever is established. The treatment principally consists in obtaining gradual, and at the same time free, evacuation of the fluid, restraining the motions of the chest, and supporting the general strength. As the discharge ceases, the lung may in part expand; it may, however, continue collapsed, become consolidated, and the chest fall in. In neglected cases, absorption of the intercostal substance takes place; the integuments bulge outwards, and distinct fluctuation is perceived. The skin has been allowed to become thin, and even to give way, without the nature of the case being known; but this can be the result only of ignorance or of inattention. In such cases, the ribs have been denuded, and become necrosed to a large extent,—the sequestra separating slowly and in fragments; and causing long-continued and wasting discharge. It is plain, therefore, that pointing of the matter should never be waited for. Chronic collections are occasionally met with of some years’ duration, and producing great enlargement of the chest. Surgical interference with such is less likely to prove beneficial than with the acute.

Wounds of the large bloodvessels of the chest, or of the cavities of the heart, are almost immediately fatal. Mere punctures, however, of these parts, have closed for a time, and in some cases even permanently. All wounds of the chest, though not involving bloodvessels of a large size, are productive of severe consequences—effusion of blood or bloody fluids into the cavities, escape of air into the external cellular tissue, collapse of the lung, and inflammation and its results, are always to be dreaded. The danger is not uniformly tantamount to the extent of injury inflicted. Individuals have recovered from extensive wounds causing profuse hemorrhage, and great displacement and laceration of the parts; whilst, from much slighter injuries, untoward and fatal consequences have quickly resulted. Wounds may penetrate the chest, and be continued into the abdomen; the stomach, liver, and intestines—one or all—may be perforated as well as the lung; in such cases the hemorrhage is in general speedily fatal. Injury of the intercostal arteries, and of the mammary and its branches, is attended with serious bleeding. It is easily arrested, however, by pressure. A piece of fine linen is pushed into the wound, followed by charpie, so as to form a small bag within the chest, a little larger than the opening; by pulling this gently outwards and fixing it, efficient pressure is made on the bleeding vessel. At the same time the motions of the chest are to be restrained by bandaging; indeed this is necessary in almost all injuries of that part. When reaction has been established, antiphlogistic treatment must be pursued, and it generally requires to be extremely active. Bloody, serous, or purulent fluids, lodging in the cavity of the pleura, are to be evacuated, if need be, either by incision or by enlargement of the original wound. In the course of the cure hectic usually supervenes to a greater or less degree, and requires the reverse of the previous treatment.

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.