Gdth^uJjLj OPERATION STRANGULATED INGUINAL HERNIA; FROM THE TREATI8E BT SIR ASHLEY COOPER, Bart. boston : • PUBLISHED AT THE MEDICAL IMUBLLIfiKIICER OFFICE, SO. 47, MARLBOROUGH-STREXT. John Cotton, printer. Sir A. Cooper's treatise on hernia, part 1st, folio, ■was published 1804 ; part 2nd, 1807, price dol. 42.— In 1812, the author said he could not procure a copy of it, which he was desirous of sending to M. Scarpa. *• . INGUINAL HERNIA. No disease, belonging to surgery, requires in its treatmen greater anatomical knowledge, with surgical skill, than hernia. Symptoms, im- mediately threatening extinction of life, occur at times, in situations, that afford but little op- portunity for consulting others, and demand * prompt resolution and decisive practice, special- ly to meet occurrences, when the knife becomes the only method of saving the patient. The operation should be performed before soreness of the belly under pressure occurs. The patient is to be placed on a table, about three and a half feet high, his body horizontal, except the shoulders a little raised, his legs, as high as the knees, hanging down over the edge of the table, and the thighs a little bent, to re- lax the abdominal muscles. The bladder should be emptied, the diseased side shaved. The sur- geon, between the patient's thighs, grasps the tumour with his left hand, and with a scalpel in the other, makes an incision the whole length of the tumour, uulese it is very large, beginning 4 opposite to the upper part of the abdominal ring, at the middle of the sac, and ending at the bot- tom of the tumour in the same direction. This incision, through the skin and cellular membrane, divides the external pudendal artery, which always crosses the sac and spermatic cord near the ring. The bleeding may be stopped by an assistant's finger, or by ligature. The inci- sion exposes the fascia from the external oblique muscle, which forms the first and thickest cov- ering of the sac. The middle of this fascia is next cut through, and a director, introduced be- neath it, is carried upward (toward the head) to within an inch of the ring, and the fascia divided upon it; turning the director downwards, a similar division of the fascia is made to the bottom of the tumour. This opening exposes the second cover- ing of the sac, viz. the cremaster muscle, which must be divided upward and downward, as the fas- cia. To surgeons not accurately acquainted with the anatomy of the part, these layers cause great embarrassment and delay; the operator, expect- ing to see the sac as soon as he has divided the integuments, cuts the fascia with extreme cau- tion, fibre after fibre, from fear of injuring the intestine, mistaking this thickened covering and the cremaster for the sac. 5 When the sac is exposed, if the hernia is in- testinal, and the intestine does not adhere to the sac, fluctuation may be generally perceived at its anterior, inferior part when the tumour is grasp- ed and the fluid it contains pressed forward.— The surgeon pinches up by dissectors' forceps, some of the cellular membrane which closely ad- heres to the anterior, inferior part of the sac, places the edge of the knife horizontally, cuts a hole to admit the blunt end of a director, on which the sac is to be further divided, to within an inch of the abdominal ring, and to the bottom of the sac. The reason that the anterior, infe- rior part of the sac is selected for the puncture is, the intestine seldom descends so low ; if it does, a fluid is generally between it and that part of the sac, unless the intestine adheres to the sac, or the hernia is omental. If the intes- tine and omentum have descended, the latter generally covers, sometimes envelopes, the in- testine. The omentum is only a shade darker than natural; the intestine is covered with coag- ulable lymph. The surgeon carries his finger into the sac to examine the situation of the stricture ; he will find it at the abdominal ring; 2ndly, where the sac opens into the abdomen, i. e. from 1£ inch to 2 inches above it, outwards towards the spi- 2 6 nous process of the iliu^i, occasioned by the low- er edge of the transverse and oblique muscles, or at both places: 3dly, in the mouth of the her- nial sac ; pressure of parts above the ring has been often mistaken for this sort of stricture. If at the abdominal ring, the surgeon passes his finger as director into the sac to the stric- ture, ihen a probe-pointed bistoury between the ring and the sac, and insinuating it within the ring, cuts through it directly upward, (to avoid the epigastric artery) opposite to the middle of the sac, sufficiently to return the parts without violence. In general, if the finger can be readily admitted into the abdomen, the dilatation is suffi- cient. If the stricture is of the 2nd sort, the surgeon introduces the flat side of the bistoury towards the finger, till he insinuates it under the stric- ture ; then turning the edge of the knife for- ward, by a gentle motion of its handle he di- vides the stricture sufficiently to allow the fin- ger to slip into the abdomen; the knife is then withdrawn with its flat side towards the finger. This orifice is divided straightly upward oppo- site the middle of the mouth of the sac. If the stricture is within the sac, dilatation of the transversalis is insufficient to liberate the in- testine. Then the finger being carried within 7 t.C>0, a poor woman, at Kings- wood, appeared sinking fast, under crural her- nia. She fell down stairs a fortnight before, and soon after discovered a tumour in her groin, uhirh gave excruciating pain, produced vomit- ing and constipation, which had continued from that period to the time I saw her. Mortification had begun ; no other direction was given but that her strength should be supported. In a few days the mortified parts began to slough; the whole of the feces passed through the arti- ficial anus, 3 months, during which time several inches of one of the small intestines were dis- charged at the wound. At the expiration of 3 months, a small portion of the feces began to take the natural cour/e; the quantity gradual- ly increased till, C months from commencement of the symptoms, the feces passed entirely by the rectum, and the wound healed. A few days after mortification had began in the groin, a tu- mour formed near the ilium, on the same side, which mortified ; an inch of intestine was dis- charged; the wound continued open a month. She took largo quantities of bark and cordials 11 during confinement, and is now as well as she has been fur many years." j. cooper, Surg. Wotton Under I'<-lge, Gloucester. A patient of Mr. Cowell, in St. Thomas' Hos- pital, had, a long time, irreducible omental hernia on the right side ; a second protrusion formeda tu- mour on the outer side of the old hernia. This last became strangulated ; the operation was per- formed ; the protruded intestine was found mor- tified, and was therefore left in the sac. For 3 weeks after, feces were discharged in part from the groin, most by the amis. A month after the operation, the intestine began to protrude at the wound, became inverted, and from that time the feces ceased to pas? by the rectum. He lived 11 years more; he died 1778. Part of the co- lon, opposite the entrance of the ileum, and the ileum itself had sloughed away ; adhesions of the intestines to the orifice of the wound, and to each other, had prevented feces escaping into the abdomen; whilst the ileum was preserved from protrusion, feces escaped in part intb the colon ; when a protrusion happened, communi- cation with the colon was stopped.—During Un- healing of the wound, support the intestine and prevent its inversion. If a small hole only has been produced, the intestine should be returned into the abdomen. 12 except that portion in which the hole is. A nee- dle and ligature should be passed through the mesentery at right angles with the intestine, to prevent its including the branches of the mesen- teric artery which supply that part of the intes- tine, then through the mouth of the sac; tying the thread, the intestine becomes confined to the mouth, and the feces pass from the opening, but in part by the rectum. The intestine is grad- ually shut, and an artificial anus is effectually prevented. "July, 1794, a man, ret. 22, had, for six days, strangulated hernia of the right groin ; the symp- toms had been, five days, so mild, they had not excited sufficient alarm. He had constant sick- ness, tight belly, extreme soreness of the tu- mour, without any stool for the above mention- ed period. The sac was without fluid, closely embracing a considerable portion of the ileum, which, with the sac, was gangrenous. On en- deavouring to separate, in the n ost tender man- ner, the gut from its adhesions, it burst, and its contents immediately c-caped. Effecting the separation, so as to draw out the whole of the diseased part, with a sufficient portion of mesen- tery, 4 inches of intestine were found destroyed, which and the srav.grcncus porlitn of the sar were, removed. 13 Gastroraphy being effected, two stitches were passed through the mesentery on each side of the divided intestine, and secured to the pa- rietes of the wound. An emollient clyster was thrown up, and cloths moistened with spirit ap- plied over the abdomen. He was ordered an opiate, and lightest food sparingly. On the morrow-evening no evacuation had passed by stool, his belly was more distended, he was equally sick as before, now and then teased with hiccough, the wound seemed very unhealthy. I removed the stitches on the intes- tine, bringing its open extremities just without the wound, to allow discharge of air or feces from the superior part of the canal.* In the night, when he appeared almost expiring, a sud- den, violent discharge of air and feces burst from the wound in immense quantity. Immedi- ately his pulse rose, comfortable warmth suc- ceeded, his stomach became settled, hiccough left him, and from that day each symptom became more promising. 10th day, the parts looked so well and healthy, 1 again brought the extremities together by su- ture. Most of the stitches gave way to the con- * Qu. Might it not be proper, on any such occasion, to allow time for escape of accumulation above the di- vided part ? 14 tinual pressure to which they were exposed.— Union was effected at the sides of the intestine; the sections there consolidated resembled a dou- ble-barrelled gun. Feces continued to pass wholly through the wound, till the patient, acci- dentally having made slight pressure on the part, soon after felt inclination for stool, which, by the usual efforts, he passed to his great joy. It occurred to him, compress and bandage might assist him to gain power of natural dis- charge. He had daily discharge of feces and wind per anum, could prevent escape by the wound, of feces however liquid. He was sup- plied with a truss, which completely answered the purpose. From the time of the operation, the wound underwent very considerable changes. At first, the patient being quiet in bed, making little or no exertion of the abdominal muscles, the wound remained on a level with the surface of the in- teguments ; when he began to give his body more motion, the wound sunk inward, the ex- tremities of the intestine appeared at the bot- tom of a sulcus, forming near half a cylinder, an inch in diameter. He could walk about his grounds, get on his horse, without restraint." Mr. Nayler, Surgeon of Gloucester-Hospital. 15 Bispham, a woman of Tottenham, had for ma* ny years femoral hernia, which, in the summer of 1801, became very painful, without interrupt- ing the regular course of her bowels, and con- fined her to her bed on account of the extreme pain she felt on attempting to put her leg to the ground. She remained several days in this slate. I made several fruitless attempts to re- duce the hernia, and, a week afterwards, as pain and inability to move continued, the operation was performed. A minute portion of inflam- ed intestine firmly adhered to the mouth of the sac. Feces were able to pass it; it be- came painfully compressed at every attempt to extend the thigh, which was the cause of the inability to move. With great care the adhe- sions were separated, and the intestine returned. The sac was large, and had been considerably detached from the surrounding parts. I easi- ly dissected away the whole sac; then passed stitches through its mouth so as to bring the edges into perfect contact. The ligatures were drawn out of the external wound. 6th day the ligatures came away ; the wound was healed the 10th. A month after, I saw the woman; hernia as large as the first, had formed on the same spot. She came for a truss, finding on every at- tempt at exertion she felt a powerful forcing- 16 down in the tumour, which was rapidly increas- ing. I saw her two years after; immediately on removing the truss, which had been worn ever since the operation, the hernia freely de- scended. C. Beegey, aet. 54, admitted into St. Thomas' Hospital, Friday, Feb. 4, 1803, had been subject to hernia from his earliest years; it was produc- ed by a bruise on the pummel of a saddle. It had always been in a great degree reducible; whenever he emptied the sac as much as he could, something remained in it. Monday, Jan. 31, it became painful whilst he was at work, and could not be in any degree reduced; almost at the same moment he was seized with colic and vomiting. Tuesday, Feb. 1, all the symptoms were in- creased ; he had had a small stool; it afforded him no relief. Wednesday, Thursday and Fri- day, the symptoms continued to increase; he was then admitted into the Hospital. The tu- mour was enormous, reaching half way to the knees, hard, painful on pressure. The abdo- men was hard and tense, but little painful. He was sick, occasionally vomited, had had no stool since Tuesday. Many attempts were made to reduce the hernia. 17 l made an incision, 3 inches long, immediate- ly over the abdominal ring, exposing it with the knife, as well as the fascia it sends off. I made a hole in the fascia to introduce a director, which I thrust up between the ring and sac, without dividing the sac ; passing a curve probe-point- ed bistoury on it, I divided the ring, introduc- ed my finger, and feeling some resistance from the transversalis, I carried the bistoury on the director to it, and divided it. Slight pressure was sufficient to return the part, which did not adhere. The man was soon relieved of pain. 16 hours after, I found him free from every symptom of strangulation, scarcely suffering from the wound. Whenever he coughed, the tumour increased largely in size, though easily reducible, nor could any endurable pressure keep it supported in coughing. Had the sac been opened, the continual irritation upon its contents, must probably have been fatal. He had no bad symptom ; in a week he could bear a laced truss. In 3 weeks, the wound was healed. A lady, ast. 68, had long suffered under enor- mous irreducible ventral hernia, now strangu- lated. Various attempts had been made to re- turn the part. The omentum and intestine ad- hered to the sac and each other; return of the 18 parts was impracticable ; the sac was too large to be separated from the integuments and re- turned. I regretted I had opened it. All that could be done was to dilate the stricture, and sew the integuments closely together. Vomit- ing and pain in the abdomen immediately ceased: she had a passage through the bowels. Next day, inflammation took place in the integuments and sac, the abdomen became very tender, and 37 hours after the operation she died. The operation in which the sac is not open- ed may be employed when the surgeon is con- vinced, from his general experience, that the parts if reduced, will resume their functions. NOTE. The best position for Taxis is by laying the patient on his back, putting a pillow under the pelvis, another under the shoulders, the thighs elevated to a right angle with the body, the knees so close together as only to admit of the surgeon's arm between them: this relaxes the aperture through which the hernia first quits the abdomen.