Chapter XXIV: Part 24

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.