With Author’s Compliments STRANGULATED HERNIA: The Importance of Its Early Recognition and Advantages of Prompt Operative Interference BY I. P. KUNGENSMITH, M. D., F. S. Sc., BLAIRSVILLE, PA. Surgeon Pennsylvania Railroad ; Ex-President Westmoreland County (Pa.) Medical Society; Member and Ex-President Indiana County (Pa.) Medical Society ; Member Medical Society of the State of Pennsylvania ; of the American Medical Association ; of the British Medical Associa- tion ; of the National Association of Railway Sur- geons ; of the Pittsburg Obstetrical Society ; Fel- low of the Medico-Legal Society of New York ; Corresponding Member New York Academy of Anthropology; Fellow of the Society of . Science, Letters and Art of London, Etc. REPRINTED FROM "MEDICAL BRIEF” OF JULY, 1894 BLAIRSVILLE, PA. 1894 STRANGULATED HERNIA: The Importance of Its Early Recognition and Advantages of Prompt Operative Interference V I. P. KLINGENSMITH, M. D„ F. S. Sc., pa. Surgeon Pennsylvania Railroad ; Ex-President Westmoreland County (Pa.) Medical Society ; Member and Ex-President Indiana County (Pa.) Medical Society ; Member Medical Society of the State of Pennsylvania ; of the American Medical Association ; of the British Medical Associa- tion ; of the National Association of Railway Sur- geons ; of the Pittsburg Obstetrical Society ; Fel- low of the Medico-Legal Society of New York ; Corresponding Member New York Academy of Anthropology ; Fellow of the Society of Science, Letters and Art of London, Etc. REPRINTED FROM "MEDICAL BRIEF” OF JULY, 1894 BLAIRSVILLE, PA. 1894 Blairsville, Pa. Press of the Evening Courier 1894 i Reprinted from the Medical Brief, July 1894.) *STRANGULATED HERNIA: The Importance of Its Early Recognition and Ad- vantages of Prompt Operative Interference BY I. P. KL1NGENSMITH, M. IX, F. S. Sc. Surgeon Pennsylvania Railroad, Blalrsvtlle, Pa. In the scope of this brief paper I will coniine my remarks more particularly to the importance of an early diagnosis and the necessity of prompt operative interference. The most important feature associated with the successful treatment of strangulated hernia is an early diagnosis. As practitioners are familiar with the various methods of diag- nosis, it is unnecessary to enter into the details of this feature ; but, on the other hand, I will endeavor to emphasize the im- portance of being ever on the alert where the vomiting is per- sistent, and not defer a thorough examination of those regions where hernias are most liable to exist, until our suspicions are aroused by the appearance of stercoraceous vomiting. During the summer months when gastro-intestinal dis- *Read at a meeting of the Indiana County (Pa.) Medical Society, May 8th, 1894. 2 eases prevail and the vomiting is persistent, the possibility of the existence of an intestinal obstruction should be borne in mind, and, under these circumstances, it should be made an invariable rule to examine the groin. While care must be ex- ercised so as not to mistake a small, incomplete, strangulated hernia for inflamed glands, nor a scrotal hernia for an attack of orchitis ; yet, where a tumor exists in those regions where hernias are most liable to appear, and the vomiting is persis- tent, the existence of hernia should receive the benefit of the doubt. In all cases where the diagnosis is obscure, the surgeon should not hesitate to make an exploratory incision, thereby enabling him to ascertain the true pathological condition. In attempting to reduce a strangulated hernia, unless the patient can remain perfectly quiet, a general anaesthetic should be administered. As posture is an important factor, the patient should rest upon the back, with the thighs flexed upon the abdcmen and the pelvis elevated. In this position gravity carries the intestine and omentum toward the dia- phragm, and when aided by gentle taxis on the neck of the tumor, facilitates reduction. An expedient which has in numerous cases, in my prac- tice, proven successful, has been to prepare the strangulated hernia by the application of an ice-bag. This relieves the local pain and shrinks the swollen parts, often making reduc- tion quite easy ; in fact, so much so, that in several cases of very recent hernia, upon returning to the bed-side of the pa- tient an hour or two after having made the application, to my astonishment, I found the mass reduced. In another series of cases of successful reduction, the above method was supplemented by the administration of a general anaesthetic, while the body was elevated by placing the legs of the patient over the shoulders of a third person, gentle taxis on the neck of the tumor being made. But, as many cases coming under our observation,—espe- 3 cially if the hernia has been of some hours’ standing,—do not yield to these milder measures, it will now be in order to consider the importance of prompt operative interference. Statistics show the value and importance of early operation, as sometimes delay of only a few hours will produce compli- cations which not only require more time in their removal, but will, at the same time, necessitate a more intricate opera- tive procedure, which, had the operation been done earlier, might have been obviated. The older teachers of surgery always cautioned the prac- titioner to defer the operative treatment of a strangulated hernia for a certain length of time, which was generally con- sumed in vain attempts at reduction; consequently the old statistics of herniotomy present a high mortality, when con- trasted with recent operations. This striking contrast has been brought about, not solely by an improved technique and antiseptic methods, but is due in a great measure, to the modern teaching that it is dangerous to delay an operation, which, when done early, is recognized as one of the safest pro- cedures ol modern surgery. Vain and prolonged attempts at reduction of a strangu- lated hernia aggravate the cause which has produced the strangulation. As all surgical operations of any magnitude are attended by some shock, it is, therefore, an imperative duty to resort to surgical interference, when the organs of cir- culation and the nervous system are in the most favorable con- dition to resist the immediate effects of the operation. Enough has been said in favor of early operation, in that class of cases which do not readily yield to milder measures, that to temporize with such cases by the administration of drugs, treating them upon what is known as the expectant plan, un- til gangrene has taken place, should be considered as a gross negligence and a reflection upon modern, aggressive surgery. A safe rule which I have found to work well for all prac- 4 tical purposes, is to make gentle taxis ; should this not suc- ceed, I place an ice-bag over the tumor and visit my patient again in an hour or two, when an anaesthetic is adminis- tered, with the understanding that, if this fails, an immediate operation shall be done. In order to save time and a second narcosis to the patient, everything should be in readiness for the operation before giving the anaesthetic. It is unnecessary to enter into the minute details of the technique of the procedure, beyond impressing the necessity of observing strict cleanliness or asepsis, as the time, in fact, has long since gone by when, instead of meeting criticism by argument, we are able to point with just pride to the benefi- cent effects of modern antiseptic surgery. As set forth by the writer in a paper on “ Antiseptic Sur- gery in Railway Practice,” read before the fourth annual meeting of the National Association of Railway Surgeons, held at Buffalo, N. Y., in 1891, “ To sum up, briefly, my prac- tice is to carry out absolute cleanliness on the part of myself and assistants, cleanliness on the part of the patient, instru- ments and dressings, and the use of antiseptic solutions.” When, therefore, operative interference becomes imperative, the surgeon should have in view the object of effecting a radi- cal cure. I will not occupy your time further by entering into the details of the operation, as the principles involved in the va- rious methods for the radical cure of hernia are practically the same in all: to dissect out the sac and excise it and to en- deavor to close the hernial canal. As personal experience has proven to me the danger of dividing the constricting fibres with a blunt-pointed bistoury, on the grooved director or finger nail, from within outward, I wish here to condemn that old and classical practice, and give my endorsement to the modern method of making a free 5 incision with the scalpel, under the guidance of the eye, from without inward. Of the modern methods for the radical cure of strangu- lated hernia, those of McBurney, MacEwen and Bassini are in greatest favor, the former being preferable on account of its greater simplicity. These diiferent methods are all passing through a period of probation, yet the results have been of a sufficiently encouraging character to warrant their repetition. li V THE SAME AUTHOR Treatment of Typhoid Fever.—Medical Record, August 25th, 1883. Vol. 24, page 204. Calomel in Diphtheria.—Medical Record, July 12th, 1884. Vol. 26, page 36. Incontinence of Urine.—Archives of Pauliatrics, Sep- tember, 1884. Vol. 1, page 557. Hay Asthma.—Transactions Ninth International Medical Congress. Vol. 4, page 11. A New Aseptic Pocket Surgical Case.—Medical Rec- ord, June 28th, 1890. Vol. 37, page 737. Chronic Hypertrophic Rhinitis.—Medical Brief, March, 1891. Vol. 19, page 257. Antiseptic Surgery in Railway Practice.—Official Transactions National Association of Railway Surgeons, 1891. Page 19. The Proposed “ Pennsylvania Railroad Surgical Society.”—Surgical Department Railway Age, September 25th, 1891. The Care of the Injured by the Pennsylvania Rail- road.—Official Transactions National Association of Railway Surgeons, 1892. Page 46.