^
THE LIBRARY
OF
THE UNIVERSITY
OF CALIFORNIA
PRESENTED BY
PROF. CHARLES A. KOFOID AND
MRS. PRUDENCE W. KOFOID
PRACTICAL OBSERVATIONS
ON
STRANGULATED HERNIA,
AND SOME OF THE DISEASES
OF THE
URINARY ORGANS.
BY JOSEPH PARRISH, M. D.
KEY & BIDDLE, 23 MINOR STREET.
1836.
N.\ .
Entered according to the act of Congress, in the year 1835, by Key & Biddle,
in the Office of the Clerk of the District Court, of the Eastern District of
Pennsylvania.
Philadelphia:
T. K. <fc P. G. Collins, Printers,
No. 1, Lodge Alley.
TO
PHILIP SYNG PHYSICK, M. 13.
The fathers of the medical profession in the days of my
pupilage are gone — but thou art still among us. Permit one who
knew thee in the vigour of manhood, and listened with deep
instruction to thy private lectures, before thy elevation to a
Professor's Chair, thus publicly to acknowledge the numerous
acts of kindness and confidence received at thy hands.
Under these feelings, can I do other than cherish recollec-
tions of the past, accompanied with a desire, that now, when
the shadows of evening are lengthened out, consolations may
gather thickly around thee, soothed by the consciousness of a
faithful discharge of duty, and remembering that a grateful com-
munity are prepared to acknowledge that thy " lamp has burned
for the good of others?"
THE AUTHOR.
iV]350917
PREFACE.
It would seem to be in accordance with the general
principles, which ought to regulate the intercourse of
man with his fellow man, that a reciprocity of informa-
tion and good feeling, should constitute a common
stock, and be converted, if possible, to the common
good.
For the accomplishment of this object, it may not
be essential that every man should bring in large ac-
cessions of treasure, procured by the efforts of unri-
valled talents.
Even those plain and simple offerings, which are the
result of observation and experience in matters of fact,
that have been subjected to the examination and ap-
proval of common sense, may be entitled to some nook
or corner in the great storehouse of knowledge, where
congenial minds may enter and examine them.
With these views I have undertaken the task of
writing a book. Not without the forebodings that may
accompany any common mind, that has read the wish
of a very ancient writer. Oh that mine enemy had
written a book.
VI PREFACE.
There is one consolation, however, in the behef that
enemies, if I have any, must be very few, and so far as
my own feelings are concerned, none.
Therefore, with a firm reliance on the kindness and
candour of the medical profession, and an earnest de-
sire to be preserved from doing harm, even if no good
is accomplished, I commence the book.
It has long been my opinion, that men possessing
similar casts of mind, and engaged in the same pro-
fessional pursuits, will often very naturally arrive at
the same conclusions on subjects that are brought be-
fore them.
They may most honestly believe, and announce dis-
coveries, when, to their no small disappointment, they
have to realize an ancient declaration, " There is no-
thing new under the sun."
Angry feehngs have been excited by conflicting claims,
and the charge of plagiarism has been set up by one
party, and denied by the other.
■ Inasmuch as the meaning of this w^ord, among men
of science, is somewhat analogous to certain terms of
disgrace, which are used by persons engaged in trade
or business, the writer feels particularly anxious to
avoid even the appearance of such an evil.
In the acquirement of medical knowledge, throughout
my life, an aptitude has been indulged to open the ave-
nues of the mind to the influx of information. This has
been derived from various sources; from books, espe-
cially from the book of nature, whose leaves have been
PREFACE. VH
unfolded durii)g many a midnight hour, at the bedside
of the jDatient, as well as in the dissecting room. Con-
versation with medical brethren has also been a pleas-
ing and fruitful source of knowledge.
In the course of time, by reflecting on the facts and
observations thus accumulated, some ideas or views
may have opened to my mind, which may seem to be
new, that may be derived from another source, and yet
if called upon to state all the circumstances, from the
first conception of the idea, until full birth, I should fail
in the attempt.
In order, then, to avoid all future collision and diffi-
culty, it is my desire, if possible, to introduce at the
outset, some quit-claim, or renouncing clause, to new
ideas and discoveries.
Being no lawyer, and never having sued a man in
my life, there may be some difficuky in putting the
matter in proper form. Thus much may serve the pur-
pose, viz: Know all men of the medical profession, that
the author of this book will immediately renounce
all claims to new ideas and discoveries, as soon as the
same may be made to appear. He will not enter into
htigation, or require any other proof, than plain asser-
tion from any respectable source, on which he will
immediately confess judgment; provided the claimant
will on his part covenant and agree, to use his best
exertions to render his own, and all other useful in-
formation in the healing art, as free as the air we
breathe.
In conclusion, it may be proper to remark, that my
Vlll PREFACE.
medical pupilage was under the direction of an excellent
and beloved preceptor, Caspar Wistar, M. D., who was,
at that time, Adjunct Professor of Anatomy and Sur-
gery in the University of Pennsylvania. Since enter-
ing on the arduous duties of medical life, I have been
placed in some responsible stations, which necessarily
cast me in the way of some experience. In my earlier
years, I laboured a long time among the poor in the
Philadelphia Dispensary. During one of our visitations,
I was appointed by the Board of Health, resident phy-
sician at the Yellow Fever Hospital, then situated on
the eastern bank of the Schuylkill, on the extensive pre-
mises formerly known as the " Wigwam." In this situ-
ation, ample opportunity was afforded of observing this
disease during life, and of pursuing dissections after
death.
After this, in our Almshouse Infirmary, and in the
Pennsylvania Hospital, two of the largest institutions
of the kind in the United States, it was my lot to have
a considerable share of laborious business. While in
private practice, in the bosom of a community wherein
I was born, and in a city where some of my ancestors,
in the days of Penn, lived in a cave on the western
bank of the Delaware, enjoying liberty of conscience,
I have gratefully to acknowledge a full portion of con-
fidence and patronage.
Now, while no claim is set up for superior talents, I
may at least be allowed the possession of a competent
share of common sense. Not that double refined and
re-sublimated sense, in which some excel; but that \^ hich
PREFACE. IX
is adapted to practical purposes in our journey through
life. To industry, I must and ^vill lay claim; it is ad-
mitted to be a very humble ingredient in human cha-
racter, and within the reach of the plainest capacity.
Yet I set so much store by it, that should it be ques-
tioned, I could, without a blush, call all Philadelphia to
bear me witness.
I have long been engaged in imparting practical
information to numerous private pupils. Scarcely any
thing has afforded me greater pleasure, than to walk
through the wards of a hospital, followed by a number
of medical students, and to observe their close atten-
tion to clinical instruction.
Having now, for full thirty years, been labouring in
my vocation as a daily practitioner, and having pre-
served a record of many important cases, I have been
encouraged to commit some of the results of my expe-
rience to the press, and thus appear before the public
as the writer of a book.
I have selected Strangulated Hernia, and some of
the Diseases of the Urinary Organs, as the subjects of
my first essays.
Should this work meet a favourable reception, per-
haps it may prove the prelude to a series of medical
and surgical observations, to appear in due course.
But if its value has been overrated, it may at least
be permitted quietly to occupy some nook or corner of
the storehouse already noticed, where it may repose in
oblivion, along with its author.
B
CONTENTS.
PAOsr.
Preface, --------- iv
Introduction, --------i
PART FIRST.
ON STRANGULATED HERNIA.
CHAP. 1. — Difficulties in the Diagnosis of Hernia, 9
Section i. Hernia mistaken for Colic, - - - 10
Case. Hernia mistaken for Colic, - - - 12
Section ii. Deceptive Symptoms, - - - - 14
Case. Strangulated Hernia with Fecal Discharge, 16
Section hi. Diseases resembling Hernia, - - - 18
Enlarged Glands, - - - . {f}^
Cirsocele, - - - - - 20
Varicose Vena Saphena, - - - 21
Hydrocele, - - - - - ih.
Old Hernial Sac, - - - - ih,
CHAP. II. — Treatment of Hernia, - - - 23
Section i. On the means of Reduction employed before
the Operation, - - - - - ib.
Blood-letting, - - - - - ih.
Purging, - - - - - - ib.
Opiates, ------ ib.
Tobacco Enema, - - - - - 24
fVarm Fomentations, - - - - 25
Taxis, ------- /^,
Xll CONTENTS.
PAGE.
Section ii. On the Operation for Inguinal and Femoral
Hernia. 28
Section hi. On the propriety of opening the Hernial ,
Sac, -.___. 36
Case. Seat of Strangulation within the Sac, - 38
Section iv. Difficulties of opening the Hernial Sac, - 47
Case. Hernial Sac concealed by a Coagulum of
Blood' - - 48
Case. Distinction between Sac and Intestine con-
fused by Gangrene, - - - - 52
Case. Hernial Sac, at first, 7nistaken for Intestine, 53
Case. Inguinal Hernia — Stricture in the Sac —
Adhesion of Omentum. - - - 56
Section v. Difficulty of Reduction from Inflammation, 57
Case. Strangulated Ventro-inguinal Hernia —
Adherent Intestine — Cure, - - - 58
Case. Inguinal Hernia — Strangulated, dark,
and inflamed Intestine, - - - 62
Section vi. Symptoms of Strangulation after Reduction
by Taxis, - - - - - 64
Case. Hernia — Reduction by Taxis — Symptoms
continued — Stercoraceous Vomiting —
Recovery, - - - - - -66
Case. Note, 71
Section vii. Symptoms of Strangulation after Operation, 72
Case. Scrotal Hernia — Symptoms of Strangula-
tion after Operation — Cure, - - 73
CHAP. III. — Diagnosis of Mortification, - - 80
Section i. On the Constitutional Evidences of Mortified
Bowel, - - - - - -lb.
Case. Strangulated Scrotal Hernia — Gangrene
— Death, 81
Case. Strangulated Femoral Hernia — Deceptive
Symptoms of Gangrene, - - 85
Case. Strangulated FemoralHernia — Apparently
Mortal Symptoms — Reduction by Stra-
monium, ------ 88
CONTENTS. Xlll
PAGE.
Section ii. On the Proofs of Mortification on opening
the Sac, 93
Case. Strangulated Hernia — Intestine dark, re-
sembling Mortification, - - - 95
Case. Femoral Hernia — Dark colour of Bowel —
Stercoraceous vomiting — Recovery, - 98
CHAP. IV. — On the Management of Mortified
Bowel, 103
Case. Ventro-inguinal Hernia — Mortified. Spots
— Testicle involved in the Tumour — Death, 106
Case. Note — Strangulated Hernia — Operation
— Consecutive Mortification — Effusion
—Death, - - - - - 109
CHAP. V. — Artificial Anus,- - - - - 114
Case. Note — Artificial Amis formed by Abscess
— Partial Recovery, - - - - 1 1 5
Case. Note — Artificial Anus formed by Abscess
— Recovery, - - - - - -116
Case. Umbilical Hernia — Sloughing externally
— Natural Cure, - - - - 117
Case. Artificial Anus — Exhaustion — Death, - 119
Dr. Physick's Operation, - - - - 121
CHAP. VI. — Entero Epiplocele, - - . _ 124
Expatriated Omentum, _ _ _ 125
Case. Entero-epiplocele — Expatriated Omentum
— Excision — Cure, - - - - 139
Case. Ibid, 149
Case. Ibid, 150
Case. Irreducible Entero-epiplocele — Stercora-
ceous Vomiting — Operation — Death, - 154
Case. Ibid, - - - - - - -156
Mortified Omentum, - - - - 156
Case. Entero-epiplocele — Mortified Omentum —
Sloughing of the Mortified Mass — Re-
covery, - - - - - -159
XIV . CONTENTS.
PAGE.
Case. Gangrenous Omentum discharged by Jih-
scess — Radical Cure, - - - - 166
Inflamed Omentum, - - - 168
Case. Entero-epiplocele — Omentum Inflamed —
Return into Cavity — Death, - - 169
CHAP. VII.— Concealed Hernia, - - - - 173
Case. Concealed Hernia — Strictured Bowel flac-
cid— Death, 174
Case. Strangulated Inguinal Hernia — Jipparent
Reduction by Taxis — Death, - - 176
Case. Strangulated Inguinal Hernia — Stricture
at Internal Ring — Small Tumour ex-
ternally — Strangulated eight days —
Recovered, ----- 179
Case. Strangulated Scrotal Hernia — Jipparent
Reduction — Recovery, - - - 182
CHAP. VIII.— Umbilical Hernia, - - - - 186
Case. Umbilical Hernia — Mortiflcation of the
Integuments — Death, - - - - 187
Case. Umbilical Hernia — Radical Cure, - - 190
CHAP. IX. — Strangulation within the Abdomen, 194
Case. Constipation — Obstruction produced by
Diseased Omentum — Death, - - 195
Case. Strangulated Scrotal Hernia — Stricture
divided — Obstruction continued from
vUhesions ivithin the Abdomen, and
Distension of Bowels, - - - - 197
CHAP. X. — Anomalous Cases, _ _ _ . 202
Case. Hernia — Sudden Death from Strangula-
tion, ------- ib.
Case. Entero-epiplocele — Gradual Approach of
Strangulation — Double Sac — Death, - 203
Case. Hernia — Semi- Strangulation, - - 205
Case. Mortified Spots producing Death — Hyda-
tid in the Sac, - . - - . 206
CONCLUSION. Corollaries, 208
CONTENTS. XV
PART SECOND.
DISEASES OF THE URINARY ORGANS.
PAOE.
CHAP, I. — Retention of Urine, - . - - 217
Section i. Deceptive Symptoms, _ - - - 218
Case. Enorvioiis Distension of the Bladder —
Urine discharged under the Influence of
the Will— Death, - - - - 220
Case. Retention in an Infant — Bladder greatly
Distended— Death, - - . - 222
Case. Incontinence, with Retention oj Urine, - 224
Case. Retention from Exhaustion and Nervous
Irritation — Urine discharged under the
Influence of the Will, - - - . 225
Case. Incontinence and Retention of Urine, - 226
Section ii. Retention from the Effects of Cold, - - 227
Cz.se.. Retention from Cold, _ - _ . 228
Section hi. Retention of Urine in Fever, - - 229
Case. Note. Retention in Fever, - - 231
Case. Ibid. ------- ib.
Case. Retention in Fever — Deceptive Symptoms, 232
Section iv. Retention from Contusions of the Body, 233
Case. Fracture of the Pelvis and Ischuria, - 225
Case. Fractured Pelvis — Rupture of theUrethra
— Muscular Pouch in front of Bladder, 237
Section v. Rupture of the Bladder from Contusion of
the Abdomen, . _ _ . 239
C2,se. Rupture of the Bladder — Death, - - ib.
Case. Contusion of the Bladder — Lesion of the
Fundus, 240
Section vi. Retention of Urine from Contusion of the
Perineum — Tapping the Bladder, - - 242
Case. Contusion of the Perineum — Retention of
Urine from Effusion of Lymph, - 243
XVI CONTENTS.
PAGE.
Case. Retention of Urine from Contusion of the
Perineum — Tappiiig the Bladder, - 245
Section vii. Retention from Diseased Prostate, - 256
Section VIII. Treatment of Enlarged Prostate, - - ,
Case. Note. Enlarged Prostate - - - 261
Case. Ibid, ' - 264
Passage of the Catheter in Enlarged Pros-
tate, - - - . - - 265
Section ix. Retention of Urine from Pressure on the
Spinal Marrow, - . . . 269
Case. Note. Retention in Paraplegia, - - 270
Case. Note. Partial Paraplegia — Retention —
Recovery, ------ 271
Case. Injured Spine — Inflammation andUlcera-
tion of the Bladder, - - - - 272
CHAP. II.— On the Catheter, - - - 276
Directions for the Use of the Catheter, - - - 277
Section i. Difficulty in the Passage of the Catheter from
an Effusion of Blood, - - - - 282
Case. Note. Difficulty from, Blood in theUrethra, 283
CdiSe,. Difficulty from Blood in the Bladder cured
by injecting Warm, Water, - - - 285
CHAP. III. — Stricture of the Urethra, - - 288
Section I. Treatment of Stricture, - - - _ 292
Case. Note. Stricture overcome by Catheter with
a Tapering Extremity, - - - 294
On the Use of Caustic in Strictures, - - - 295
Conditions in which Caustic is hnproper, - 297
Case. Rupture of the Urethra from the Use of
Caustic, - - - - - -298
Rupture of the Urethra, and Effusion of Urine into
the Cellular Tissue, ----- 301
Case. Rupttired Urethra — Effusion without Gan-
grene, 303
Section ii. Fistula in Perineo, - - . _ 305
Case. Note. Fistula in Perineo cured by Caustic, 306
Case. Ibid, 307
CONTENTS. XVU
PACK.
CHAP. IV. — Tic Doloureux of the Urinary Blad-
der, 309
Case. AWe. Tic Boloureux of the Bladder, - 310
Case. Ibid, ib.
Case. Tic Doloureux of the Bladdei' — Death, - 312
CHAP, v.— Nephritis, - - - - - - 314
Caee. Note, ------- 315
Case. Note. Passage of a Calculus through the
Ureter 316
Treatment of Nephritis, 317
Gout affecting the Kidneys, - - - - 321
Case. IrritableBladder and Urethra — Disorgan-
ization of the Kidney — Death, - - ib.
Case. Ibid, 323
CONCLUSION, 328
Explanation of the Plates, 329
INTRODUCTION
It is not the intention of the author to enter into an
elaborate anatomical description of all the parts con-
cerned in Hernia, or Diseases of the Urinary Organs.
Such descriptions would be required in a work de-
signed to be strictly systematical; but it would interfere
with the present plan of the writer.
It is to be presumed that medical men, who engage
in practical surgery, have acquired, by previous study
and dissection, a competent knowledge of anatomy.
They ought to be familiar with the relative situation
of parts, especially blood-vessels, and should strive
to understand those probable derangements in natu-
ral position, which may be caused by distension sud-
denly induced, or by gradual and morbid changes in
structures. The situation occupied by the epigastric
artery in inguinal and ventro-inguinal hernia, should be
distinctly understood.
A chapter is expressly devoted to directions for per-
forming the operation, as it may be required in the
several descriptions of hernia; and a number of cases
are given, which show the safest plan of dividing the
stricture, according to my experience; yet I feel par-
ticularly anxious that the subject of femoral hernia
should be clearly understood.
The exact position of the epigastric artery must
ever be borne in mind, because, if an ignorant and in-
1
2- INTRODUCTION.
cautious operator attempted to make an incision
through the crural arch upward and outward^ he would
very probably divide the epigastric artery near its
origin.
I have sometimes feared there may be too much
anatomical nicety in the description of hernia. The
various layers of fasciae may tend to confuse a young
operator. Far be it from me, however, to give to the
indolent pupil the slightest pretext for ignorance and
carelessness.
When I was in the frequent practice of demonstrat-
ing, before my pupils, the parts concerned in femo-
ral hernia, I deemed it of primary importance to give
to the learner a simple and distinct idea of the real
seat of stricture, detached from every other consi-
deration appertaining to the subject. This may be
done by dissecting through the integuments, and re-
moving from the groin the lymphatic glands, and all
other obstructions to the passage of the finger under
the crural arch into the abdomen.
Let the index finger be now pushed firmly in a direc-
tion towards the pubis — then bend the first joint of the
finger and slowly withdraw it from the crural arch. In
doing this, the pupil will be sensible of a sharp or acute
tendinous edge that he has hitched upon his finger.
This is the real seat of stricture in femoral hernia. It
is the reflected edge of Poupart's ligament, and may
with great propriety be called Gimbernat's ligament,
because this surgeon first called the attention of the
profession to this particular structure.
1 can enter into the feelings of a young operator
when his skill may be tested in a case of femoral her-
nia, perhaps in some situation remote from many ad-
INTRODUCTION. 3
vantages to be met with in a city — not even anatomi-
cal references. If well-informed, he will be likely to be
diffident; he may begin to tax his memory about all
the precise anatomical details connected with femoral
hernia. He may be startled at the fear that some im-
portant points have been forgotten. For a time he may
be confused. It is a moment for him to be collected and
firm. Let him calmly reflect and simplify his subject.
After he has, by safe and careful dissection, opened the
hernial sac, conformably to the rules laid down, what
is the point to be kept steadily in the eye of his mind?
Is it not the true seat of stricture. To find this, let
him introduce his finger along the strangulated part,
on the side next the pubis, and then with the very tip
of his finger he may recognise the sharp tendinous
edge of Gimbernat's ligament. Here fears may again
assail him. He may suppose that, in dividing the stric-
ture, he may wound the epigastric artery, the sperma-
tic chord, &c. Let him lay aside his fears, and, con-
formably to directions, introduce the curved blunt-
pointed bistoury under the stricture, on the inner side
of the strangulated bowel towards the pubis, and in
the very gentlest manner divide the stricture upwards.
He will be delighted to find what an extremely slight
«ncision will be sufficient to enable him to pass his
finger into the abdomen by the side of the strangu-
lated part. The epigastric artery lies on the outward
side, and is secured from harm by this procedure. I
have for many years pursued this course, generally
inclining the edge of the bistoury a little inward, and
have never had reason to suspect that I ever inflicted
an injury on the spermatic chord, or epigastric artery.
4 INTRODUCTION.
It is hoped the solicitude I feel on the subject of fe-
moral hernia will be excused, even if some tautology
should be found in the course of the work. Considerable
complexity is necessarily connected with this subject,
when viewed in all its parts. My object is to disentangle
it from difficulties as far as possible, and to fix the mind
of the operator, as he is about to proceed, upon the
simple and prominent points which will guide him safely
in his course.
It is not in accordance with the plan of the writer to
take up the consideration of trusses. Various instru-
ments of this description are before the public. Each
must finally stand on its own merits. It is also worthy
of remark, that surgeons are far from being the sole
umpires on this subject. Hernia is a very common
disease, and a numerous body of persons have had
ample experience in the use of the truss. Many of
these individuals are men of intelligence and reflection,
who feel themselves qualified to form a judgment of
their own. Hence public opinion will materially regu-
late this subject, independently of the medical pro-
fession.
On diseases of the urinary organs, I would simply ob-
serve, that an accurate anatomical knowledge of the
parts, both in a natural and morbid condition, is of the
highest importance. Without this, a practitioner would
fail in his efforts to relieve a patient from great suf-
fering and danger, at a moment when his services
were imperiously demanded. With it, he may prove
the instrument of speedy relief from one of the most
painful conditions to which the human frame can be
subjected.
INTRODUCTION.
In addition to anatomical knowledge, there is a pe-
culiar tact in the use of the catheter, that can only be
acquired by practice; it is, therefore, highly necessary
that the student should avail himself of every opportu-
nity to introduce the instrument on the dead subject.
The position of the third lobe of the prostate, and
the manner in which its enlargement produces reten-
tion of urine, and obstructs the passage of the catheter,
is worthy of attentive observation. A preparation of
a diseased gland in spirits, with the urethra attached,
answers an excellent purpose for illustrating this diffi-
culty. I have endeavoured to convey to the reader a
clear idea of this subject, by referring to several plates
appended to this volume. The drawings were executed
by an ingenious artist of this city, from preparations
now in my possession.
ERRATA.
At the dash line, p. 57, the following caption has been acci-
dentally omitted.
SECTION V.
DIFFICULTIES OF REDUCTION, FROM INFLAMMATION.
Throughout the work, for stercoracious^ read stercoraceous.
PART I.
STRANGULATED HERNIA.
ON
STRANGULATED HERNIA.
CHAPTER I.
DIFFICULTIES IN THE DIAGNOSIS OF HERNIA.
It is not an easy task, in some cases of hernia, to
determine the real nature of the disease; and from
want of attention on the part of the surgeon, serious
and even fatal mistakes have been made. The utmost
care is sometimes necessary in the examination of the
patient ; and when all caution is employed, it is still
possible for the experienced surgeon to be deceived.
Without attempting to describe every cause of error
in the diagnosis, it is proposed, in the present chapter,
after premising an outline of the common symptoms
of hernia, to describe such causes of mistake as have
been illustrated by cases occurring under my own
observation.
The symptoms of strangulated hernia are as fol-
lows : pain and tenderness in the tumour, and extend-
2
10 HERNIA MISTAKEN FOR COLIC.
ing over the whole abdomen, particularly about the
umbilicus. In the early stages, the pain occurs at short
intervals, gradually becoming more fixed. At the very
onset of the attack, an evacuation from the bowels
frequently occurs ; after which the discharges are sus-
pended; retching and vomiting ensue, and the stomach
rejects all kinds of medicine or aliment. If these symp-
toms continue for a short time, fever is developed ; the
abdomen becomes swollen and tender ; and the patient
is thrown into a state of distressing and constant
torment, which is fully depicted in the countenance.
Among the most alarming symptoms are, singultus,
tympanitic abdomen, and stercoraceous vomiting. This
last mentioned symptom is generally considered a fatal
one, but I have known recoveries after this event. At
last there is a cessation of all pain; the patient lies
calm and comfortable, and he and his friends may sup-
pose that the danger is over. This idea is delusive.
There is, indeed, an exemption from suffering, but the
clammy sweat, the death-like coldness, and the feeble-
ness, or absence of the pulse, proclaim to the practi-
tioner that death is at hand. The strangulation has
caused inflammation, which has terminated in mortifi-
cation.
SECTION I.
HERNIA MISTAKEN FOR COLIC.
There are certain associations connected with words
that have an important bearing on practice — thus : if
I were called upon to select an example, I should un-
HERNIA MISTAKEN FOR COLIC. 11
hesitatingly say, that colic ought always to he associated
with the idea of strangulated hernia. I dehver it as an
opinion that facts will sustain, that if the practice were
universal to suspect every case of colic to be a case
of strangulated hernia, many valuable lives would be
saved.
The symptoms of cohc and hernia are so com-
pletely identified, that, in a majority of cases, no hu-
man skill can discriminate between them without the
most careful investigation. The attendant symptoms
of an incarcerated bowel differ in no respect from those
of a severe attack of colic. Thus, violent spasmodic
pain in the abdomen, frequent retching and vomiting,
and constipation of the bowels, so often met with in
colic, are also observed in strangulated hernia. The
symptoms, in both cases, are produced by the same
cause, an obstruction in the course of the alimentary
tube. In colic, however, the obstruction is produced
by a spasmodic contraction of the muscular fibres of
the intestine, which usually yields to a proper applica-
tion of relaxing and anti-spasmodic remedies ; while, in
hernia, a portion of the bowel is closely impacted and
retained in a small space, and in an unnatural position,
from which it can only be relieved by returning the pro-
truded parts to their proper situation.
Let me, therefore, enforce the precept so clearly
founded in reason — in every case of colic suspect stran-
gulated hernia. Painful experience has taught me,
that a constant attention to this injunction is of the
utmost importance. I have frequently been called
by respectable practitioners, unaccustomed to sur-
gery, to consult with them upon what they deemed
obstinate cases of colic, when an examination of the
12 HERNIA MISTAKEN FOR COLIC.
groin has revealed the true cause of the symptoms to
be a strangulated bowel! Too often this discovery-
has been made at a juncture when all the symptoms
declared that the prospect of success from an opera-
tion was very slight, or that the relief of the patient
was beyond the reach of human skill. Numerous cases
of this description have fallen under my notice. I shall
content myself at present with briefly noticing one of
these, which illustrates, in a striking manner, the im-
portance of making the necessary examination ; others
of a similar character will be found in the sequel.
CASE I.
Hernia mistaken for Colic,
I was called to visit the wife of a respectable farmer,
reported to be very ill with colic. 1 obtained from the
attending physician the following history of her case.
Two days previous to my visit, while sweeping the
parlour, she was suddenly seized with violent pain in
the abdomen, vomiting, and all the symptoms marking
an attack of colic. The family physician, a man of
great respectability and skill, was immediately sent for,
and steadily pursued the usual means for overcoming
the symptoms until the evening in which I saw her in
consultation. The doctor informed me, that he had
found the case so obstinate that he had feared intus-
susception. The bowels had not been moved from the
commencement of the attack.
Before going into the room, I stated to him that I
suspected strangulated hernia, and requested him to
HERNIA MISTAKEN FOR COLIC. 13
make an examination of the groins. In a short time
he returned, and confirmed my suspicion. A small
tumour was discovered in the left groin. It was pain-
ful to the touch, and could scarcely be detected by the
eye, as it was covered with a considerable quantity of
adipose matter.
The condition of the patient was by this time very
critical. Her pulse was feeble, but her tongue was
moist, and the abdomen bore pressure very well. Her
countenance was sunken, and her complexion of a
bluish cast. Under these circumstances, it was thought
advisable to propose the operation, as affording the
only hope of success. After candidly stating my
views to the patient and her husband, they at once
consented to the operation. An opiate was adminis-
tered by the mouth, and by enema; and I proceeded
by candle-light.
After making the incisions through the integuments
and fasciae, I exposed a small femoral hernia. The
sac was carefully opened, and a small quantity of fluid
escaped, having a slight cadaverous smell. A portion
of the intestine was of an ash colour, and flaccid —
a state of things which I consider highly unfavourable.
The finger was introduced to the point of stricture,
which was readily divided.
Directly after the operation, the pulse was very
feeble, and the skin cool; but after the patient was
placed in bed, her system re-acted, and she expressed
herself much more comfortable. I left her late in the
evening.
Next morning I received a letter from her physi-
cian, informing me that she died at about two o'clock,
A.M.
14 DECEPTIVE SYMPTOMS.
I would here impress upon the surgeon the import-
ance of making a thorough and minute examination of
the different points at which the protrusion in hernia
is hkely to occur, and not to be content with a super-
ficial view. For, though he will generally be able to
decide upon the case without difficulty, yet circum-
stances do sometimes occur which tend to obscure the
tumour, and may lead to uncertainty. I shall mention
a case in the sequel in which I was myself deceived,
and I have no doubt others have been similarly situated.
Nor should the surgeon rely simply on the state-
ment of the patient, without examining for himself.
The tumour may be so small as to escape the atten-
tion of the individual affected ; it may have occurred
very recently, and may not have been noticed ; or, as
sometimes happens in the case of young and modest
females, its existence may be concealed from motives
of false delicacy.
On the whole, in every suspicious case, it is the safer
plan for the surgeon to make for himself a careful ex-
amination. No harm can result from pursuing this
course, while an observance of it, I am convinced,
would tend very much to the safety and profit of the
patient, and to the credit and usefulness of the medical
attendant.
SECTION II.
DECEPTIVE SYMPTOMS.
When the bowel is suddenly subjected to strangula-
tion, the 'pinch received by this delicate part must
DECEPTIVE SYMPTOMS. 15
naturally excite, for a moment, an increase of peri-
staltic action, which, operating below the stricture,
may prove sufficient to expel the fecal matter, and
thus a free stool may be one of the first evidences of
strangulated bowel. This very symptom is so en-
tirely the reverse of the common opinion entertained
of incarcerated intestine, that even a practitioner, un-
accustomed to the disease, might readily conclude
that there could not exist any mechanical obstruction
to the passage through the alimentary canal. Under
this impression days may elapse, and the proper period
for successful operation may pass over, before he
discovers his mistake. Other causes may operate to
keep up this deception, until mortification and death
reveal the truth.
Some years ago, I was called, by my departed
friend Dr. Knight, to visit an aged widow in Keys'
alley. The symptoms of strangulation were per-
fectly plain; the operation was proposed, and con-
sented to by the patient ; and the hour fixed for its
performance ; but, on our meeting again for the pur-
pose, she had changed her mind, and would not sub-
mit. The patient and her female attendants insisted
upon it that her bowels were opened, and that she
passed flatus very freely. In a few days the patient
died. I examined the body after death, in company
with Dr. Knight, and found a portion of bowel stran-
gulated and mortified.
Another instance, somewhat similar to this, occurred
in the Pennsylvania Hospital. A patient was brought
in, and reported to have had discharges of fecal mat-
ter and flatus ; yet, on operating, a portion of bowel
was found incarcerated and sphacelated. The patient
16
DECEPTIVE SYMPTOMS.
died. Several instances, strongly confirmatory of the
views here advanced, will be found in the succeeding
pages ; and the details of one case of this kind will
be added at the close of this section.
I am inclined to believe that many of these decep-
tive symptoms depend upon the frequent use of injec-
tions, especially when administered on the old fashioned
plan of pipe and bag. In this way it often happens
that a considerable portion of air is injected into the
bowels, and, when returned, may convey the idea of
an open passage from the stomach to the anus. The
enema may also bring away a sufficient portion of fecal
matter to colour the injected fluid, which, without close
inspection, may pass for a real stool.
CASE 11.
Strangulated Hernia withfcBcal discharge.
9th mo. 20th, 1819. — I was called this morning to
the Pennsylvania Hospital, to consult with my col-
leagues, Drs. Hewson and Hartshorne, on the case
of an old coloured man affected with strangulated
inguinal hernia.
The tumour was distinct, and the symptoms of stran-
gulation sufficiently marked, though less severe, than
in ordinary cases. As his stomach was retentive, we
agreed to try the effect of purgatives for a few hours.
We directed jalap and cream of tartar to be adminis-
tered frequently, and in divided portions.
In the afternoon we met again. The house-sur-
geon reported that he had taken siss. of jalap mixed
DECEPTIVE SYMPTOMS. 17
with cream of tartar, and had retained it on his sto-
mach, hut without any effect upon his bowels. The
tumour was still firm, and the symptoms well marked.
We concluded to advise the operation immediately
after making the necessary preparations; and, as we
were about to have the patient carried to the operat-
ing room, he had a copious evacuation from the bowels,
accompanied with a discharge of flatus. This cir-
cumstance induced us to delay the operation, suppos-
ing that the stricture had at least partially yielded.
We then left the patient, to meet again on the follow-
ing morning.
21 5/. — On visiting the patient this morning, we found
that his symptoms were still more alarming. In addi-
tion to pain and constipation, he was affected with
vomiting and singultus. The tumour was firm, and
no discharge had followed that which occurred at our
last visit.
We at once concluded to operate. Dr. Hewson
performed the operation. On laying open the sac, a
portion of intestine was found in a state of high in-
flammation, and coated with a thick layer of coagulated
lymph. We concluded to detach the lymph before
returning the parts; which was readily effected by
means of the handle of the scalpel. The intestine
was very much thickened by inflammation; so that
Dr. H. was obliged to dilate the ring freely, in order
to accomplish the reduction. The patient bore the
operation very well, and recovered completely under
Dr. Hewson's care.
18 DISEASES RESEMBLING HERNIA.
SECTION III.
DISEASES RESEMBLING HERNIA.
There are several diseases occurring in the parts in
which hernial tumours are generally developed, which
may, by the inattentive observer, be mistaken for it ;
and a practice may be instituted, in consequence, which
may lead to serious results. In a large proportion of
cases, the mere examination of the external tumour
will be sufficient to decide the nature of the complaint.
In small hernia, however, and especially when the
tumour is obscured by fat, a more accurate examina-
tion is often necessary ; but little doubt can be enter-
tained, even under these circumstances, when the his-
tory of the case is minutely investigated. Still, as
mistakes in the diagnosis have sometimes occurred, it
may be proper to notice some of the diseases with
which hernia is confounded.
One of the most common sources of error arises
from an enlarged state of the inguinal glands, forming
a tumour resembling in size and shape a hernia. In-
stances are on record of hernial tumours being treated
as inflamed glands until the period for successful treat-
ment has passed by. Cooper and Petit relate several
cases of this description which fell under their notice,
in which the error proved fatal to the patient; and
Lawrence tells us, that he knew a hospital surgeon of
considerable eminence, who allowed a patient to die of
strangulated hernia, under a belief that the tumour in
DISEASES RESEMBLING HERNIA. 19
the groin was a chain of inflamed glands. A post
mortem examination revealed the true cause of death.
I have never met with a case in which this error
proved fatal, though I have known inflamed glands to
be mistaken for hernia. I was called, late one even-
ing, to visit a patient, in consultation with two respect-
able physicians. The messenger was very urgent, and
requested that I would come prepared to operate.
On arriving at the place, 1 found a man who ap-
peared to be in great distress, complaining of violent
pain in his abdomen, &c. I soon discovered, how-
ever, that his violent iflness was altogether a pretence,
and that the tumour in the groin was a venereal bubo !
He had been attempting to deceive his medical attend-
ants, for the purpose of concealing from his friends
his real situation, and had completely succeeded.
Another very similar case occurred to me. I was
called, by a respectable medical practitioner, to see a
patient with whom he had been labouring for a consi-
derable time, to reduce a rupture. He had been freely
bled, and the taxis had been diligently tried, and the
physician now called on me to operate. On examining
the tumour, I immediately recognised a venereal bubo.
On mentioning the fact to the patient, he promptly and
positively denied it. I then pulled back the prepuce
and exposed a large chancre on the glans penis. This
terminated the consultation.
The following note from my case-book presents an
unusual complication of circumstances leading to de-
ception.
Sth. mo. 1822. — In a late case at the hospital, which
I saw in consultation with Drs. Price and Hewson, we
supposed the patient to labour under a strangulated
20 DISEASES RESEMBLmb HERNIA.
hernia. He represented, that he had been subject to
hernia for some years, and had been in the habit of
wearing a truss ; that he had lost his truss at sea, and,
since that accident, his rupture had descended. He
was at this time labouring under an attack of gonor-
rhoea, with considerable swelling of the scrotum and
surrounding glands. He had fever, and his bowels
were moved by medicine. The tumefaction in the
groin was very considerable, and resembled very much
the tumour of an omental hernia. He was directed
bleeding from the arm; leeches to the abdominal ring ;
the recumbent posture, with the hips elevated ; and we
determined to watch the case and consult again if
necessary. In a short time it was discovered, that
the tumour resembling hernia arose from an abscess
which had formed in the groin ; and that the real old
hernia was on the opposite side, and had not been
altered from its usual appearance.
A frequent source of error in the diagnosis of hernia
arises from the appearances presented by the spermatic
veins when in an enlarged or varicose condition. This
disease, called circocele, is very common, particularly
among young men; and is frequently mistaken for
hernia. I have been called upon very often by indivi-
duals affected with circocele who have worn trusses
for a considerable time, under an impression that they
laboured under hernia; and, not unfrequently, their
fears have been confirmed by their medical advisers.
In cases of doubt, the point may be readily settled
by requesting the patient to lie down ; when, in the
circocele, the tumour immediately recedes : moreover,
it communicates to the touch a peculiar sensation ; so
that when grasped between the thumb and finger, it
DISEASES RESEMBLING HERNIA. 21
resembles a bundle of worms entwined together be-
neath the integuments. To render the case still more
plain, the abdominal ring should be carefully examined.
A case is mentioned by Petit, in which the saphena
vein was so much distended as to be mistaken for a
femoral hernia, and under this impression, a truss was
actually applied by a physician. The tumour, in this
case, was reduced by pressure, was increased by cough-
ing, was produced by the erect position, and disap-
peared in the recumbent posture.
Hydrocele of the tunica vaginalis testis, or of the
spermatic cord, has occasionally been mistaken for
hernia ; but the slow progress of the tumour, and the
transmission of light through the part, should render
the distinction certain.
I have seen one case, in which a thickened hernial
sac produced a tumour, which was a cause of decep-
tion. The patient was an old coloured man who,
some years ago, was brought into the alms-house in-
firmary, labouring, as was supposed, under strangulated
hernia. He was affected with vomiting, severe pain
in the abdominal region, tympanitic abdomen, tender-
ness on pressure, and obstinate constipation. It was
ascertained that he had been affected with rupture for
many years ; and that strangulation had taken place
occasionally. There was a distinct tumour in the
groin.
Under these circumstances, a consultation of the
surgeons of the institution was called to decide on the
propriety of an operation, and the students were col-
lected to witness it. I recognised in the man an old
Dispensary patient, whom I had frequently attended ;
and recollected that, on one occasion, I had seen him
22 DISEASES RESEMBLING HERNIA.
in an attack of strangulated hernia, and had reduced
the parts by taxis. On a close examination of the
tumour, we were all struck with its flabby and inelastic
feel, differing very much from the firm and elastic feel
of a strangulated hernia. As the case was obscure,
it was concluded to postpone the operation until fur-
ther light could be thrown on it. The next day, the
friends of the patient removed him from the infirmary,
and Dr. Hewson saw him. The symptoms continued
unabated, and the patient died.
Dr. Hewson obtained permission to examine the
body, and found that the tumour was caused by a
hernial sac very much thickened by chronic inflamma-
tion. This old sac had been affected with recent and
violent inflammation, which had extended to the peri-
toneum, and involved it also in general high inflamma-
tion.
CHAPTER II.
TREATMENT OF HERNIA.
SECTION I.
ON THE MEANS OF REDUCTION EMPLOYED BEFORE THE
OPERATION.
Various remedies have been proposed by surgeons
for relieving a strangulated bowel, before proceeding
to an operation. The object of all these is to bring
on a general relaxation of the system, and quiet the
irritability and pain of the patient. Some such mea-
sures should certainly be employed, and among them,
hlood-letting holds a conspicuous rank. I have occa-
sionally seen cases of strangulation in which free
bleeding brought on relaxation, and the protruded
bowel was happily returned.
Purging has been proposed ; but this practice, where
the stricture is recent, rather tends to aggravate than
to relieve the symptoms. In cases of old and irredu-
cible hernia), the purging plan may be useful.
• Opiates arc valuable remedies when administered
under proper circumstances. Sometimes, after the
free use of the lancet, an opiate has been adminis-
tered, the stricture has given way, and the bowel has
24 MEANS OP REDUCTION
been returned, with little difficulty. The warm bath
also is entitled to a trial.
Among the most prominent means for producing
relaxation, and one which is very often employed, is
the tobacco enema. This remedy is, I believe, recom-
mended by most surgeons, before proceeding to an
operation. Such a general recommendation I consider
of doubtful propriety, particularly where the system
has been reduced by previous depletion. In cases
in which there may be a deficiency of constitutional
vigour, I should be very cautious about proposing it ;
believing that, as a general rule, the depressing effects
which it produces on some constitutions are more to
be dreaded than even the operation itself when per-
formed by a skilful hand. This opinion has been
formed from some experience. Nor am I alone in
my fears : — the distinguished Hey, of Leeds — a man
whose opinions are entitled to the greatest respect —
says that an operation should never be performed on
a patient while labouring under the effects of a tobacco
enema. He even mentions the case of a patient who
died soon after his removal from the operating table,
under the circumstances mentioned.
I was once concerned, with several other surgeons,
in a case where we were all very much alarmed at
the eflfects of a tobacco enema. The patient was
suffering from a disease of the urinary organs; and
soon after the injection was administered, he fell into
a state of the most dreadful prostration, from which
he was aroused with the greatest difficulty, by appro-
priate treatment.
I understand that a formula directing two drachms
of tobacco to the pint of water is used in one of the
EMPLOYED BEFORE THE OPERATION. 25
London hospitals. This I should consider very dan-
gerous. One drachm, or even half a drachm, I con-
sider sufficiently strong ; and even then advise its in-
troduction gradatim, carefully watching its effects.
Warm fomentations to the tumour have been pro-
posed by some surgeons : these, however, by causing
increased activity and fulness of circulation, rather
tend to aggravate, than to relieve the symptoms. Cold
applications are now generally employed ; and are, as
a general rule, much to be preferred. A bladder filled
with ice and applied to the tumour, is a common prac-
tice. I recollect a case in which, after a free bleedings
this plan was resorted to, and the bowel speedily re-
turned by its own efforts.
Much has been said and written about the taxis, and
much may be properly said, for the subject is an in-
teresting one. For my own part, I am inclined to con-
sider taxis in hernia, and crepitus in fracture, as two
unhappy words. They are so intimately associated
with the idea of mechanical force, that the poor pa-
tient may be subjected to an increase of pain and dan-
ger by their application to practice. Thus I have seen
a young house-surgeon, with more zeal than know-
ledge, work away upon a lower extremity almost with
the force that would be employed in mauling rails;
and, while twisting and pulling the limbs of the poor
patient, his ear was at certain points so adjusted, as
to catch the sound of a crepitus, to decide the ques-
tion of fracture ! If a practice of this kind was ob-
viously improper, and calculated to increase the pain
and inflammation of the injured parts, how much more
improper must it be when applied to a strangulated
and inflamed bowel ! Thus, when I was a student, I
4
26 MEANS OF REDUCTION
once saw a medical practitioner take off his coat, and
fall to work at the taxis in a case of strangulated her-
nia, with all the force and industry that would be re-
quired for some laborious mechanical operation. He
pushed and dug at the poor patient at a terrible rate,
and all without success !
Now let common sense speak on this subject. What
can be more irrational than to apply force to a tender
bowel already in a state of inflammation ? What more
likely plan to hurry on the bowel to mortification, and
the patient to death? I lay it down as a principle
that all force in such a case is improper — arte non vi
should be the maxim of the surgeon.
There is another view to which this subject is enti-
tled. Let not the young surgeon despise the innate
capacity which even the ignorant possess, of adapting
means to their own relief which are the result of their
own experience. I have often met with patients who
were expert in performing the taxis for themselves ;
and for many years past, I have not permitted profes-
sional pride to prevent me from requesting patients to
try their own skill in the reduction of the rupture. To
illustrate these remarks, I will state a case. An igno-
rant servant-woman was violently attacked with a small
strangulated femoral hernia. When the patient was
in a state of relaxation, and at a favourable moment
for the trial, I requested her to " try to put it up ;" and I
carefully watched her movements. She laid upon her
side, inclined the trunk forward, drew up her knees,
and flexed the thighs upon the pelvis; thus causing
complete relaxation of the abdominal muscles and
fasciae, and, by her own efforts, reduced the incarce-
rated bowel.
EMPLOYED BEFORE THE OPERATION. 27
An old anatomist of a facetious turn, and fond of
his stomach, used to say, that after taking so much
pains to inform himself of the structure of the parts
concerned in deglutition, he could not swallow better
than other men ; — and the oldest and most experienced
surgeons must admit that, in some cases, even the igno-
rant compete with them successfully in performing the
operation of the taxis ; — but let not this anecdote be
construed by the indolent into a plea for inattention
and ignorance.
The celebrated Desault was so fully convinced of
the great danger of immoderate efforts in applying
taxis, that he condemns it in almost every instance.
In his opinion, the bruising and other injuries inflicted
on the bowel by the surgeon, in such attempts, may
render the state of the patient as critical after the
reduction, when accomplished^ as it is before the reduc-
tion. Desault has witnessed many cases that tend to
show a great difference in the mortality after operat-
ing, in favour of those operations which have been
performed on patients who have not been previously
subjected to the taxis. " You may always hope for suc-
cess," he says, " in a hernia which has not been touched
before operating."*
He often succeeded completely in operating upon
patients who had not been tampered with, even after
the strangulation had continued four or five days ; but
when strong efforts had been made to reduce the her-
nial contents, he almost constantly met with a fatal
result.
* Ouvres Chirurgicales par Bichat, p. 3.34.
28 OPERATIONS FOR INGUINAL
SECTION 11.
ON THE OPERATIONS FOR INGUINAL AND FEMORAL HERNIA.
After having employed without success the usual
means for the reduction of a hernia, we should pro-
ceed to the operation ; and here it may be remarked,
that much danger often arises from improper delay.
Physicians, it is to be feared, are too apt to rely on
subordinate means until at last they are obliged to
resort to the knife when too late. From six to twelve,
or at most twenty-four hours, according to the urgency
of the symptoms, affords sufficient time to employ the
ordinary means for reduction.
The longer I live, and the more I see of strangulated
hernia, the more firmly I am convinced of the correct-
ness of the observation of the distinguished Hey, given
to us as the result of a long life of experience. " I have
often had occasion to regret," says he, " that I per-
formed the operation too late, but never that I perform-
ed it too early.''''
When the operation is concluded upon, it is my
uniform practice, as in most other operations, to give
an opiate, either by the mouth or rectum. I am aware
that the general application of this practice is objected
to by some men of high character : — it is said that
opium is a stimulant, and tends to excite the system,
produces fever, &c. This fear, I believe, is grounded
in theory rather than in practice. I give opium to
prevent fever, and believe the practice not only to be
successful, but rational. The calming influence gene-
AND FEMORAL HERNIA. 29
rally produced by this article tends to lessen the pain
of surgical operations, and the shock which they occa-
sion ; and hence, it assists in mitigating one of the great
sources of subsequent reaction and fever. I have never
seen any other effect produced by it, though I have
employed it very generally in my surgical practice.
Having prepared the necessary instruments, the pa-
tient should be placed on a convenient table, and the
parts over and around the tumour are to be shaved.
Supposing the hernia to be scrotal, we commence the
incision a small distance above the external abdominal
ring, and extend it downward over the tumour nearly
to its termination. In doing this, some small branches
of the external pudic artery are divided, which, though
of no great consequence, should be secured by liga-
tures, to prevent the blood from confusing the parts as
the operation advances.
In the first incision, it is my practice to pinch a fold
of the skin, covering the tumour with the fingers of the
left hand, and to request an assistant to do the same
on the opposite side. The sharp pointed bistoury,
with its back towards the tumour, is passed through the
elevated portion of skin, and the cut made upwards :
in this way a large incision is speedily eflfected, with-
out the least risk to the parts below. Care should be
taken to have the wound of sufficient extent to prevent
subsequent embarrassment.
After the first incision through the skin, a coat of
dense cellular membrane presents itself, which must be
carefully divided. This is easily done by cutting with
a sharp pointed bistoury upon a small silver director.
This latter instrument seems to be despised by some
modern surgeons, who tell us we should depend upon
30 OPERATIONS FOR INGUINAL
our powers of skilful dissection with the scalpel. Their
advice may tend to foster professional pride, but it is
certainly not judicious if safety and expedition are
desirable. The director is passed under a layer of
this cellular fascia, and a free incision is made upon
it. By adopting this plan, all risk of wounding the
bowel is prevented, and the cellular substance can be
divided much more rapidly than by using the scalpel,
especially in femoral hernia.
Much has been said of the different layers of fascia
to be divided before coming to the sac : these are de-
monstrated with the greatest minuteness and accuracy,
and are well calculated, from their apparent complexity,
to alarm the young practitioner. This extreme ana-
tomical nicety appears to me unnecessary ; — no matter
how many layers are presented, they must be divided
until we arrive at the tendon of the external oblique
muscle, and expose the sac.
Having reached the sac, the most important part of
the operation commences. On opening it, the surgeon
is often assailed by difficulties which I shall endeavour
to expose in detail hereafter. We will suppose, how-
ever, that the case is a plain one. The sac will be
found to contain fluid, sometimes in considerable quan-
tity ; and a distinct point of fluctuation presents itself,
as in an abscess. This spot should be selected for the
opening.
The opening should be made with caution. The
prominent point of the sac should be ^^mcAec? up with
a small pair of forceps, and a sharp thumb lancet or
scalpel applied, and carried obliquely upward. The
sac being opened, the fluid will at once escape. If it
be of a bloody colour, it may alarm the young prac-
AND FEMORAL HERNIA. 31
titioner, but this is neither uncommon nor unfavourable.
Having made the puncture, introduce the silver direc-
tor, and cut upon it with the blunt-pointed bistoury, in
order to make an opening sufficient to admit the fin-
ger. This is to be considered the best instrument for
ascertaining the seat of the stricture, and the best safe-
guard against accident. In doing this, the blunt-point-
ed bistoury should be employed, and the sac freely
divided so as to present a full view of its contents.
The finger, with the nail closely pared, should then be
carried up to the neck of the sac, and the seat of stric-
ture is, in general, readily ascertained.
At this stage of the operation, it is important to
recollect the relative position of the epigastric artery
and the hernial sac. In the species of hernia of which
we are now speaking, where the bowel passes down
through the abdominal canal, the artery is found on
the inner side of the neck of the sac ; while in ventro-
inguinal hernia it lies upon the outside of the neck.
As it is sometimes difficult to distinguish these two
varieties of the disease, it becomes a matter of import-
ance to fix a rule whereby we may escape the artery
in the event of encountering either form.
Various directions have been given by different wri-
ters, in regard to the direction of the incision at the
ring : some have advised that the surgeon should cut
upward and outward ; while others, of high character,
have recommended a directly opposite course. Others
again, have been determined in their choice of direction
by the position of the spermatic cord.
These different opinions may tend to confuse and
embarrass the operator ; it is therefore the safest plan
<^
32 OPERATIONS FOR INGUINAL
for him to follow the advice of Cooper and others in
dividing the stricture directly upvv^ard.
The manner in which the incision should be con-
ducted, is an important consideration. The finger
should be passed gently up to the stricture, and there
retained. The blunt-pointed bistoury should then be
introduced to the same point, with its side lying flat
upon the finger. Pass the instrument up, until it is felt
by the finger to have passed under the stricture. Its
cutting edge should then be carefully turned up, and a
very slight movement is generally suflicient to relieve
the strictured part, and enable the operator to pass his
finger by the side of the bowel into the abdomen. Here
I would remark that I am not anxious to have a sharp
instrument for this purpose, for the parts to be divided
are so firmly distended, that very little cutting is re-
quired to separate them ; and, by too free an incision,
we may enlarge them unnecessarily, and thus expose
the patient to the danger of a return, or an increase of
the protrusion after the operation.
A curved bistoury with a narrow blade I prefer to
the straight bistoury of Cooper, so generally em-
ployed. The curved bistoury carried in tha pocket-
case, the blade of which is moveable on the handle, is ,
often used. To render the incision more certain with
this instrument, the blade should be firmly secured to
the handle by a tape string. I am in the habit also of
shielding the cutting edge, to within a short distance
of its point, by wrapping around it a piece of fine rag
or tape.
The stricture may exist both at the internal and
external ring, or at either of these points separately.
Should a stricture be discovered at the external ring,
AND FEMORAL HERNIA. 33
this should be divided, and if any difficuhy occurs, the
finger should be passed on in the direction of the inter-
nal ring, to ascertain its state, before any attempts are
made at reduction. Should it be impossible to reach
the strictured point by the finger, the director must be
substituted.
Having removed every cause of obstruction, we are
next to return the protruded parts, supposing the case
to be one in which nothing occurs to contra-indicate
this course. This should be done in the gentlest man-
ner. If the bowel does not readily yield, the finger
should be again introduced, and a further division of
the stricture made.
The reduction being effected, the surgeon should
carefully examine the rings with his finger, until he is
fully satisfied that all the parts are in their natural
position. The external wound should then be lightly
dressed with adhesive strips; or, if the incision has
been large, the interrupted suture may be required as
an additional support. The patient should be directed
to preserve as much stillness as possible, maintaining
the limbs in the flexed position. If restlessness pre-
vail, the system should be kept under the influence of
a moderate opiate. The diet should be scrupulously
restricted to mild, farinaceous articles until all risk of
inflammation has passed away. As a means of main-
taining the flexed position of the limbs, I have found
great advantage in placing an angular box and a pillow
under the thighs and legs of the patient.
Should the bowels continue constipated after the
first effects of the operation are over, small doses of
castor oil with eneinata, may be safely resorted to.
Symptoms of inflammation of the peritoneum may
5
34 OPERATIONS FOR INGUINAL
sometimes follow the operation, owing to the extension
of inflammatory action from the strictured part : —
these should be combated by the usual antiphlogistic
measures employed according to the judgment of the
practitioner.
As a general rule, I would advise caution in the em-
ployment of rigorous measures, to prevent apprehended
danger after the operation. It should ever be borne
in mind, that the system has received a severe shock —
and after the removal of the cause which produced it,
some time should be allowed for agitation to cease.
Hence, mild and soothing treatment, with occasional
opiates, will be more likely to produce a happy result
than an indiscreet resort to rigorous antiphlogistic
means. In the subsequent narration of cases, it will
be seen that the lancet w as very seldom employed after
the reduction of strangulated parts.
I will now offer a few remarks on the operation for
femoral hernia^ which differs but little from that just
described. The tumour is generally much smaller in
this than in inguinal hernia ; and on this account I pre-
fer making a crucial incision through the integuments,
by pinching up the skin, as was recommended in in-
guinal hernia. A free incision is carried horizontally
over the tumour, and another made to cross it at right
angles. The flaps are then carefully dissected up, and
the fasciae divided with the bistoury and director until
the sac is exposed. The sac in femoral hernia gene-
rally contains very little fluid, and hence more caution
is required in opening it. The situation of the neigh-
bouring vessels also offers an additional reason for
deliberate and careful proceeding. It will be recol-
lected, that the great femoral artery and vein are con-
AND FEMORAL HERNIA. 35
tained in the same sheath which envelopes the hernia,
and the epigastric artery should also be borne in mind.
The last mentioned vessel arises from the external iliac,
just as it passes under Poupart's ligament, where it
takes the name of inguinal artery; hence its origin is
very near to the outside of the reflected edge of Pou-
part's ligament, called Gimbernat's ligament, which is
the seat of the stricture: — a very slight division of
the ligament outward would separate the artery at its
origin. In dividing the stricture, it is important, if
possible, to have the finger as a guide, and by all means
to effect the division upwards, and rather inward.
Gimbernat has advised to separate the ligament from
its connection with the pubis : — this advice I consider
quite unnecessary, as a very small division is generally
effectual.
Occasionally the obturator artery diverges from its
usual course, and winds round the neck of the sac.
Several specimens of this kind are now in my pos-
session; and a case once occurred to me in the Penn-
sylvania Hospital. I was operating on a woman for
femoral hernia, and on introducing my finger to ascer-
tain the seat of stricture, I could distinctly feel the
pulsations of an artery lying close to the point of stric-
ture. I was obliged to use extreme cautidn in pro-
ceeding, but by defending the cutting edge of the
bistoury till within a short distance of the point, and
by nibbling, if I may be allowed the term, rather than
cutting, I succeeded in dividing the stricture sufficiently
to return the protruded parts without wounding the
artery. In this case, the finger was an indispensable
guide. The case was interesting on some other ac-
counts, and will be narrated in the sequel.
36 " PROPRIETY OF OPENING
SECTION III.
ON THE PROPRIETY OF OPENING THE HERNIAL SAC.
Among the important considerations associated with
the operations detailed in the preceding section, is the
propriety of opening the hernial sac, before making any
attempt to return the strangulated parts into the abdo-
minal cavity. There has long existed a difference of
opinion on this subject. Among those distinguished
surgeons who advocate the practice of opening the
sac, Pott, Hey, Astley Cooper, and Samuel Cooper,
may be named. Some more modern practitioners
entitled to the highest respect for their experience and
skill, have considered it proper to dispense with this
part of the operation. If the reduction of the hernia
can be effected by a division of the stricture without
opening the peritoneum, they consider the risks of the
operation ,to be greatly lessened by such a course.
Many older authorities are in favour of this course in
large and old hernia. Among the advocates, we may
mention Petit, Monro, Lawrence, and, more recently,
Bransby Cooper.
For my part, I am decidedly in favour of opening
the hernial sac, and I never intend to perform the ope-
ration without so doing. Differing in this from some
of my professional friends whose judgment I highly
appreciate, and have often had occasion to prefer to
my own, I feel bound to offer my reasons for the prac-
tice which is here recommended.
The principal objections to the plan of opening the
sac, so far as I can understand them, are as follows : —
THE HERNIAL SAC. 37
In recent cases, the practice is said to be unneces-
sary, because, from the short duration of the disease,
no serious mischief can have been done to the parts,
and no evidence exists of mortification of the bowel ;
then why incur any additional risk of peritoneal in-
flammation by making an opening through this delicate
and susceptible membrane ?
If efforts have been made to reduce the contents of
the sac by taxis just before proceeding to the opera-
tion, why hesitate to eflect the same result after the
stricture is divided ? which may be done without open-
ino- the sac.
While the force of these reasons is admitted, they
have failed to bring conviction to my mind of the pro-
priety of the course proposed.
When a patient labouring under strangulated hernia
has submitted himself to a surgical operation for relief,
it becomes the duty of the surgeon carefully to weigh
all the circumstances connected with the case, to ba-
lance in his own mind the dangers to be encountered,
and in the midst of contradictory indications, to choose
the lesser evil, and draw forth, if possible, a safe and
happy result ; — thus giving the confiding suflTerer every
possible chance for life, by removing the probable
causes of danger.
Now it must be familiar to every experienced sur-
geon that, in cases of strangulated hernia, there may be
concealed mischief within the sac, which will certainly
cause the death of the patient if not timely removed,
and which it is impossible to ascertain until the sac is
laid open. It is well understood, that the seat of stric-
ture may be in the hernial sac itself The incarcerated
parts may be returned, while the symptoms of stran-
38 PROPRIETY OF OPENING
gulation may go on without the shghtest mitigation,
and a fatal result will unfold the real character of the
case.
The following is an instance which goes to show
the truth of this remark; and as I was concerned in
the case, with Dr. Joseph P. Nancrede, I have taken
the liberty of extracting it from the sixth volume of
the Eclectic Repertory, where it was first published.
CASE III.
Seat of strangulation within the sac.
Andrew Patton, a coloured man about thirty years
of age, strongly built, and of large stature, having
always enjoyed good health, had been subject to a
scrotal hernia on the right side for the last five years,
but which being well maintained in its situation by a
truss, had never occasioned the least inconvenience.
On Friday, August 10, while raising his carriage, (he
being a coachman,) he made an effort, which was suc-
ceeded by a sudden pain in the left groin, but which
appears, however, not to have been sufficiently acute
to excite alarm, or even to induce him to examine the
spot which was the seat of the pain. This occurred
about three o'clock in the afternoon. In the evening, as
usual, he returned home, complaining merely of fatigue,
and went to bed without any examination, although
the pain had not abated. At about eleven, however,
he was roused by the increase of his sufferings, which
were now so violent as to make him cry out ; vomiting
THE HERNIAL SAC. 39
and hiccup made their appearance simultaneously, and
the pain extending throughout the abdomen, but more
particularly below the navel, became excruciating.
His sufferings had alarmed him, and medical assistance
was requested at about half-past one.
Upon examining and questioning the patient as to
the probable causes of his colic, (for thus it appeared
to me at first sight,) no satisfactory information could
be obtained. After some further investigation, how-
ever, he recollected having felt in the afternoon a small
lump upon the left groin, and added that his most vio-
lent pain had been at this spot. This tumour, about
the size of a goose egg, proved upon examination to
be a scrotal hernia of the left side, strangulated.
Attempts had been already made by the patient to
effect the reduction of the tumour, and I repeated
them myself in vain. But finding the tumour very
hard, as well as the pulse, I went home in search of
my lancets, having previously administered a dose of
ol. ricini. On my return, however, after keeping the
muscles relaxed for some time, the hernia was almost
immediately reduced. The patient soon felt relieved,
the pain disappeared, not the least vestige of the tu-
mour remained, and I left him dosing.
A couple of hours afterwards, the symptoms of
strangulation were renewed, and continued the same
as previous to the reduction of the hernia. No evacua-
tion having taken place, a second dose of ol. ricini was
ordered, but was almost immediately vomited. A third
cathartic, which he kept down, produced no effect
whatever. It was then deemed necessary to take ten
ounces of blood from the arm, which, however, failed
to procure any relief. At twelve in the forenoon, no
40 PROPRIETY OF OPENING
abatement of the pain could be perceived, although
the pulse was softer; but the vomiting and hiccups
had disappeared. No passage had yet been procured ;
a dose of calomel and jalap was therefore prescribed.
Having seen him a third time in the afternoon, and no
amelioration being visible, the abdomen becoming pain-
ful to the touch, and tumefied, and still no evacuation,
a second dose of calomel with emollient injections
were recommended, and the patient w^as bled a second
time. The same situation manifested itself in the
evening, when the patient was again bled for the third
time. Although the reduction of the pulse was con-
siderable, yet it procured no relief. The vomitings
had occurred twice in the afternoon. Fomentations
on the abdomen were ordered with the injections, but
with the exception of a little relaxation in the tension
of the abdomen, no effect was produced. An infusion
of senna was administered, also in vain. I visited him
early on the morning of Sunday the 12th, and found
that his sufferings had not increased, although he had
experienced no rehef. He had not slept any during
the night. The abdomen continued painful and tume-
fied, but he complained much more of pain in the groin
on the right side than at any other point. No passage.
The injections, fomentations, and the infusion of senna
were directed to be continued. The pulse had become
tense and tremulous.
The case proving obstinate, I requested the advice
of my friend and neighbour. Dr. Povall, who agreed in
opinion that the symptoms of strangulation most pro-
bably arose from a stricture in the hernial sac, that
had been reduced with the intestine. It was deter-
mined, at his suggestion, to apply a large blister on
THE HERNIAL SAC. 41
the abdomen, and to insist upon the injection of large
quantities of warm water, with the hope of overcom-
ing the obstruction which existed. The bhster did not
produce on the skin or system any effect whatever,
and the other remedies made use of were equally in-
effectual. A copious bleeding was ordered in the after-
noon, owing to the hardness of the pulse. The night
from Sunday to Monday was equally restless. On
Monday, his situation continuing the same, it was
agreed between Dr. P. and myself that a dose of gum
gamb. and calomel should be given, and cold water
poured on the lower extremities. No effect whatever
from either. His sufferings were as great as the day
previous. The vomiting and some hiccup had occur-
red, but gave way to the camphorated mixture, which
was now recommended.
On Tuesday morning his pulse wias considerably de-
pressed, the tension of the abdomen had subsided, and
it was much less painful ; but the extremities were cold,
accompanied by clammy sweats. The voice had un-
dergone some alteration ; constant anxiety and restless-
ness were also observed. The injections were conti-
nued during the day, and a decoction of tobacco was
also added. Notwithstanding the treatment, the in-
flammation maintained its ground. No passage could
be procured. Several medical gentlemen saw the pa-
tient in the course of this day, and agreed with me in
the opinion that very little hope could be entertained.
At the suggestion of one of the gentlemen, quicksilver
was administered, in the proportion of an ounce, but
also in vain. Dr. Parrish was called to see the pa-
tient in consultation on Wednesday, and concurred in
6
42 PROPRIETY OF OPENING
opinion with Dr. Povall and myself as to the probable
cause of the very dangerous symptoms.
The pulse continued to sink, and, with some remis-
sion, when it would rise in an unaccountable manner,
gradually lost both its strength and regularity. Vomit-
ing, but more especially the hiccup, became very trou-
blesome ; and the least motion produced fresh pains.
The camphorated solution was of service in reheving
the patient from the hiccup. In this situation, when
every remedy had failed, he kept lingering until the
night of Thursday to Friday, when he expired — the
seventh day of his disease.
I proceeded the next morning to the opening of the
body, accompanied by Dr. Povall.
On opening the abdomen, we found the whole mass
of the intestinal tube, commencing at the strictured
part and extending upwards, distended with air : the
vessels of the omentum, as well as those of the mesen-
tery, very much injected with blood, and the greater
portion of the intestines bearing evident marks of in-
flammation. The seat of the disease, however, was
confined to the jejunum, which, for the length of twelve
inches, had lost its colour, and was in a complete state
of sphacelus. A portion of this intestine was confined
in the inner portion of the abdominal ring, where the
hernial sac formed a stricture round it, which having
also participated in the general mortification, w^as to-
tally disorganized, and could easily be torn away by
the nail. So complete had been this adhesion, that
when it was ruptured by a very slight eflbrt, a hole in
the intestinal canal, about the size of a shilling, was
produced. We also noticed another hole near it, of
THE HERNIAL SAC. 43
the same size, having all the appearance of an ulcer.
Having cut open the intestine at its most diseased
point for a few inches, pus, and a remarkable black
appearance on the internal coat, were observed. A
remarkable spot about the size of a half dollar attract-
ed our attention. It was situated about the middle of
the transverse portion of the colon. It was very evi-
dent to us, that the intestines contained in the right
side of the abdomen, but more particularly in its lower
region, had been the seat of a more extensive and acute
inflanuuation than those situated on the left. The in-
guinal ring, which was diseased, as we have already
noticed, on the left side, had protruded in the abdomen
as much as an inch, by the increase of its volume. —
Eclectic Repertory^ vi. p. 531.
But there is still another cause of strangulation which
may continue even after the protruded parts are re-
turned into the abdomen, and which the surgeon can-
not discover if the sac has not been laid open. The
omentum itself may become entwined around a portion
of the bowel, causing fatal strangulation. There are
several cases of this kind to be found in the books, and
Ledran mentions an instance in which a portion of the
omentum adhered to the surface of the sac of a crural
hernia, so that it formed a kind of bag within a bag,
and produced such a narrowing of the neck that the
intestine could not be returned without opening the
sac, and dividing the omentum.*
These instances present unquestionable evidence of
danger and death, which probably might be prevented,
* See Ledran — Observations in Surgery. Translated by J. S., Sur-
geon, p. 190. London, 1758.
44 PROPRIETY OF OPENING
if the sac were opened, and the actual seat of stricture
made known to the operator.
Again : the return of the mortified portion of bowel
or omentum within the abdomen, must be accompanied
with great danger; for the moment a part is positively
dead, from that moment it becomes extraneous matter,
and cannot fail to be a source of irritation and conse-
quent danger to the patient. I am aware of the diffi-
culty of reducing mortified bowel or omentum, in con-
sequence of the adhesion produced by the preceding
inflammation ; but if the stricture be divided, I believe
it may sometimes be done.
The symptoms which denote the existence of mor-
tified bowel or omentum are extremely deceptive, as
will be shown in the proper place ; and the time re-
quired to effect the death of strangulated parts is very
various. The force of the stricture, and the pecu-
harity of the constitution may, in some instances, pro-
duce very rapid disorganization.
Hence, it may happen, after a division of the stric-
ture, without opening the sac, that a mortified portion
of its contents may be pushed into the cavity of the
belly, perhaps without the operator having the slightest
apprehension of the real state of the case, which could
only be revealed by an exposure of the parts.
Let us now examine the most formidable objection
to the practice of opening the sac. It is the danger
of peritoneal inflammation, in consequence of forming
a communication with the external air.
That peritoneal inflammation is a very dangerous
and fatal disease, is a fact well known to every exten-
sive practitioner. The physician may meet with it
occasionally in its most aggravated form, without any
THE HERNIAL SAC. 45
connexion with a wound or an external injury. I
consider idiopathic peritonitis as a rare disease, when
unconnected with puerperal fever. I have met with
it in a few instances in young persons, where, for
several days, its approach has been most insidious,
being marked by a bending of the body forward, and
where dissection has. revealed evidence of violent in-
flammation with sero-purulent effusion. Its occur-
rence in puerperal fever is familiar to all. Here we
find the disease dependent on some obscure constitu-
tional cause, predisposing the system to violent inflam-
matory action in a particular part.
" Causa latet — vis est notissiraa."
I exclude from this view the various modifications
of diseased action which may arise in the progress of
fevers, &c. and which constitute the mere sequel of
acute forms of disease.
Let us now take up the subject in a surgical point
of view, and inquire whether peritoneal inflammation
is as frequent as might be theoretically supposed, even
in cases in which the peritoneum is opened by accident
or intention.
May T not hazard the opinion, that when there exists
none of those unseen and unknown causes of consti-
tutional predisposition to peritoneal inflammation to
which 1 have referred, this membrane may be opened
with less risk to the life of the patient than is gene-
rally supposed. Take, for example, the operation of
tapping in ascites. This is of very frequent occur-
rence, and here the peritoneum is punctured. I have
seen leakage through the wound take place for seve-
46 PROPRIETY OF OPENING
ral days without injury to the patient, and I would
appeal to the experience of the medical profession, as
to the frequency of inflammation and death, as a direct
consequence of paracentisis abdominis. I may have
seen inflammation, as a very rare occurrence, after
this operation, but I believe I may safely assert, that
I have never known a case resulting in death, from
tapping the abdomen in dropsy.
I have known an instance of a small shot entering
the abdomen and penetrating an intestine, to be fol-
lowed, soon after, by a copious stool of fresh blood
from the bowels, and yet the patient recovered, with-
out any serious symptoms.
Those surgeons who are acquainted with surgical
practice as it existed many years ago, must be fami-
liar with the views then entertained of the dangers
resulting from openings into the cavities of the joints
in luxations and fractures, and which were founded on
the same reasoning which now occasions the dread of
peritoneal inflammation, when a cavity is exposed.
The numerous recoveries from injuries of this class,
under the present improved mode of practice, induce
us to believe that the anticipation of dreadful results
often led to unnecessary mutilation.
From the views now unfolded, I should hope that
no young and inexperienced practitioner would pre-
sume recklessly to institute operations involving the
peritoneum, and plead me as his authority. My object
is simply to show, that in endeavouring to balance
the dangers of omitting to open the hernial sac, and
the dangers consequent upon the opening, I have long
since arrived at the settled conclusion, that to open
the hernial sac, and thus make a full exposure of its
THE HERNIAL SAC. 47
contents, is the lesser evil, and the practice most likely
to conduce to the welfare of the patient. Even if in-
flammation should follow after such an operation, may
not the injury inflicted on the bowel by severe stran-
gulation be taken into the account, as at least one of
the prominent causes, inasmuch as we knoAv that parts
are frequently returned into the abdomen, in a state of
high inflammation ?
SECTION IV.
DIFFICULTIES OF OPENING THE HERNIAL SAC.
It might be supposed, a priori, that the hernial sac
could be opened without the slightest difficulty, after
having been fairly brought into view by careful dissec-
tion. That this is the fact, is fully admitted in all
those cases where the hernia is large, and where the
sac, as is usual, contains a considerable quantity of
serous fluid.
It is said that, by careful examination, you may feel,
through the sac, the cleft between the sides of the pro-
truded bowel. I can admit the possibility of such a
case, provided it was left to the choice of the surgeon
to direct the manner in which the descent of strangu-
lated parts shall take place; but if a portion of omen-
tum, for example, should be involved in the mischief,
and should be found in the anterior part of the sac,
covering the intestine, would it not prove somewhat of
a barrier while searching for this cleft? The efflision
of lymph which we often find as the result of inflam-
mation nmst cause very considerable derangement in
48 DIFFICULTIES OF OPENING
the natural situations of the parts, and thus increase
the obscurity. If these remarks apply to a hernia of
large size, with what increased force do they bear upon
a very small portion, or knuckle of bowel, especially
in femoral hernia ! Here, it is utterly impossible to dis-
tinguish any cleft between the sides of the intestine.
It is said tliat the blood-vessels of the intestine, and
its smooth, polished surface distinguish it from the
hernial sac, which has not those blood-vessels, which
is rather rough and cellular on its surface, and which
is always connected with the surrounding parts. After
some experience in this matter, I acknowledge myself
unable to draw these nice distinctions in living struc-
tures, sometimes not inconsiderably altered by diseased
action. Having often found difficulty in distinguish;
ing between sac and intestine, and felt the vast import-
ance of avoiding the danger of inflicting a wound on
the latter while opening the former, I am willing to
communicate my experience on the subject. Let it
be remembered that, especially in some cases where a
small portion only of bowel is incarcerated, there is
no fluid in the hernial sac, and the parts are so identi-
fied, that to make a proper discrimination is a very
difficult task.
CASE IV.
Hernial Sac concealed by a coaguhim of blood.
3d mo. 10th, 1830. — W. H., a native of the West
Indies, aged about 38 years, was admitted into the
Pennsylvania Hospital about 8 o'clock, P. jyi.
THE HERNIAL SAC. 49
The following is the history of the case.
The patient had been affected with a femoral hernia
for some years, and for the last two years had worn
a truss. A few days previous to his attack, his truss
was stolen from him, since which time he had suffered
more or less pain in his rupture. About 7 o'clock,
on the morning of his admission, he was seized with
pain and vomiting, and was unable to return the bowel.
In the afternoon, he was visited by my friend. Dr.
Atlee, who directed for him free venesection and a
tobacco enema. After this, I visited him with Dr.
Atlee, and advised his being sent to the Hospital, to
which the patient consented. For several hours pre-
vious to his arrival at the Hospital he had been affect-
ed with singultus.
9 P. M. I met my colleagues, Drs. Hewson and
Hartshorne, and on examining the case, the operation
was concluded on at once. Sixty drops of laudanum
were directed, after which, about twenty minutes were
spent in preparing for the operation.
The tumour was unusually large for a femoral her-
nia, and of an oval figure, its longest diameter being
across the groin.
I made a crucial incision over the tumour, pursuing
the dissection in the usual manner, until I arrived at
a membrane, which I supposed to be the sac : I thought
it was remarkably thick. After repeated trials, I failed
to pinch up the membrane in the usual way, owing to
its firmness and thickness. I therefore cut it very
cautiously with the scalpel, being careful not to pene-
trate it.
After paring off a small portion in this manner, I
was enabled to take hold of a surrounding portion
50 DIFFICULTIES OF OPENING
with a forceps, and to continue cutting obliquely up-
ward until I had removed a considerable portion of
the membrane. Underneath this we discovered a layer
of coagulated blood, of a very dark colour.
The question now arose, whether I had penetrated
the sac, and whether the coagulum just noticed was
thrown out around the bowel and had been adherent
to the internal surface of the sac. This might have
occurred, provided the sac contained no fluid, which
sometimes happens. While this question was under
discussion, I pressed my finger firmly upon the coagu-
lum, and thought I could distinctly discover fluctua-
tion below. On examination, my colleagues were of
the same opinion, and we decided that the sac was
still undivided.
On scraping away the coagulum, the sac was dis-
tinctly seen below. Dr. Hartshorne succeeded in get-
ting a portion of it between his fingers, and I cut through
it in the usual manner. On opening the sac, a small
quantity of dark, bloody fluid escaped. I now dilated
the opening freely, with the blunt-pointed bistoury,
and passing up my finger, exposed a portion of the in-
carcerated bowel. The bowel was but little altered
from its natural appearance. The seat of stricture
was at Gimbernat's ligament; this was distinctly felt
with the index finger of the left hand; the blunt-pointed
bistoury was passed up, the stricture was divided, and
the intestine was reduced without difficulty. The
wound was closed by the interrupted suture, and the
patient placed in bed, with directions to have adminis-
tered a dose of laudanum if he became restless, and if
fever ensued, blood to be abstracted. Barley-water
ordered for drink and nutriment.
THE HERNIAL SAC, 51
llth, morning. — Patient had passed a good night.
Pulse 68 strokes in the minute. Symptoms of stran-
gulation ceased immediately after the operation. Di-
rected ol. ricini 5ss. every three hours, until the bowels
are moved. Continue barley-water. Evening. Bowels
not moved. Pulse 85. Directed oleaginous mixture
every two hours, until it operates.
\2th. — Pulse 80. Patient rested w^ell during the
night,- had two copious evacuations. Continue the
barley-w^ater, and the oleaginous mixture.
13M. — Pulse 80. Patient has taken gi. of oil since
yesterday ; has had but one discharge from the bowels.
Directed a diet of oat-meal gruel, well sweetened.
The wound has united sufficiently to allow the ligatures
to be cut out. Continue the oleaginous mixture.
\Ath. — Pulse 72. The bowels have been opened
once since the last visit. Ordered to continue the
oleaginous mixture.
15/A. — Three stools have passed since the last re-
port. The wound looks well. Pulse 68.
19//i. — The wound is now cicatrizing. The pulse
and tongue present a natural appearance, and the
bowels are sufficiently opened.
22d. — The patient placed on an improved diet. Or-
dered chicken broth, toast, butter, &c.
Ath mo. 6th. — Discharged, cured.
52 DIFFICULTIES OF OPENING
CASE V.
Distinction between Sac and Intestine confused by Gan-
grene.
9th mo. 29, 1822. — I attended this evening, with my
colleagues, at the Pennsylvania Hospital, in an in-
teresting case of strangulated femoral hernia, in which
Dr. Price performed the operation. . The tumour was
unusually small. In dissecting down through the in-
teguments and fascia?, the operator readily reached
what we all supposed to be the hernial sac. The parts
were in an evident state of sphaoelation, and the most
prominent part of the intestine, as far as we could
judge by candle-light, was of an ash-gray colour.
There w^as great difficulty in distinguishing between
sac and intestine. At Dr. Hartshorne's suggestion,
the parts were pinched up between the fingers, and we
perceived — very evidently, as we thought — the sac, dis-
tinct from the intestine. We could feel fluctuation in
the part, as if it contained a fluid. By our advice, Dr.
Price cut through the parts contained between his fin-
gers, and opened at once into — the intestine — the con-
tents of which escaped.
On a more minute examination, we discovered that
the part divided was the anterior portion of the intes
tine, which was in a state of mortification, and was
very flaccid. The deception was occasioned by the
flaccid state of the dead bowel, contrasted with the
firm and thickened living portion around it, giving the
idea of a thin membrane, covering a firmer one. It is
THE HERNIAL SAC. 53
true that no harm was done by the opening in this case,
but it exhibits a striking example of the difficuhy of
distinguishing between the sac and intestine, under par-
ticular circumstances.
The case was, in every respect, unpromising ; the
expression of the countenance w^as unpleasant, but nei-
ther the pulse, skin, or tongue gave evidence of mor-
tification.
CASE VI.
Hernial Sac at first mistaken for Intestine,
Wth mo. 25tk, 1818. — I was called, this morning, by
my friend. Dr. George B. Wood, to visit with him a
female domestic, who lived in the family of a respect-
able apothecary, and who was labouring under stran-
gulated femoral hernia.
She was attacked with symptoms of strangulation,
on the 21st inst. and was supposed, by her friends, to
be labouring under bilious colic. The apothecary had
prescribed several articles for her relief, all of which
were rejected by the stomach. Soon after the attack,
she had one discharge from the bowels ; after which
they were confined, notwithstanding the frequent use
of injections. A blister had also been applied to the
abdomen.
On the 25th, Dr. Wood was called to see her, and,
from her symptoms, at once suspected strangulated
hernia. She was cold and nearly pulseless. The doc-
tor requested that her female attendants should exa-
mine her groins ; from motives of false delicacy, the
54 DIFFICULTIES OF OPENING
patient resisted, and several hours elapsed before the
necessary examination was made ; it was then ascer-
tained that she had a small tumour in the groin, and,
at the request of Dr. Wood, I attended in consulta-
tion.
I found the patient with a cold skin ; a very feeble
pulse ; the tongue moist and slightly furred ; the abdo-
men tumid, and tender to the touch ; the countenance
sunken; and the patient complaining very much of
general distress and wretchedness. The tumour was
situated in the right groin ; it was small, and of an
oval figure.
The symptoms were so extremely unfavourable,
that I was doubtful of the propriety of an operation,
but in order to give the poor woman every chance,
Drs. Hewson and Hartshorne were called in consulta-
tion, at my request. They advised against the opera-
tion ; the patient appearing to be in articulo mortis.
We left her for the night, advising anodynes to be
given to lessen her distress. One of my pupils remain-
ed with her.
26th. — We met in consultation in the morning, and,
to our great surprise, the system had reacted consider-
ably. Her skin was warm, And her pulse, though very
feeble, had evidently improved. The pupil reported
that she had been delirious in the night, rose from her
bed, and insisted upon walking to the fire for some
minutes, and then walked back to her bed without dif-
ficulty. The favourable change in the patient's symp-
toms induced us to recommend the operation, which I
performed, assisted by Drs. Hewson, Hartshorne, Har-
lan, and Wood, in the presence of several of my pupils.
A crucial incision was made over the tumour, and
THE HERNIAL SAC. 55
the fasciae divided by the director and bistoury, in the
usual manner, until I thought I had opened the sac
and exposed a portion of intestine, that appeared to be
adhering to it. I passed my finger down by the side
of the supposed bowel, but could not feel the ligamen-
tory edge which was the seat of stricture. My friends,
Hewson and Hartshorne also examined, and were
equally unsuccessful.
Dr. Hewson now suggested that the sac was still
DO
unopened, and on close investigation this was found to
be the case. The part which we had supposed to be
intestine was the sac, and, by careful examination, the
strangulated contents could be felt within it. I suc-
ceeded in making an opening very cautiously in the
sac. No fluid was contained in it, which circumstance
rendered the obscurity so great. A portion of omen-
tum w^as found in a state of mortification, and a small
fold of bowel on the side next the omentum had an ash-
coloured slough. The cadaverous smell was observable
immediately on opening the sac. The stricture was
divided without difficulty, and the patient bore the
operation very well.
She was put to bed ; a soft poultice was applied to
the wound, (a piece of gauze intervening,) and wine
was directed in small quantities. I called in about an
hour after the operation, and found her complaining of
most severe pain in the lumbar region. Her abdomen,
which was tympanitic before the operation, appeared
to have increased in size. I was about to introduce a
tube into the colon, for the purpose of extracting the
air by the syringe, when she was seized with vomiting,
and the contents of her stomach were discharged over
the bed-clothes and floor. After this, she called to
56 DIFFICULTIES OP RETURNING
her daughter, and, in an audible voice, directed her to
go down stairs and bring up a cloth to wipe the floor;
and in less than five minutes after giving the direc-
tion — she expired.
CASE VII.
Inguinal Hernia — Stricture iti the Sac — Adhesion of
Omentum.
5th mo. 13th 1816. — I was called this day in con-
sultation with Drs. Betton and Moore, to visit a labour-
ing man, at Peter Robinson's mill, Roxborough. The
patient had a small strangulated rupture on the left
side. It could scarcely be called scrotal, but was rather
a bubonocele. He had been bled very freely, and vari-
ous unsuccessful eflforts had been made to relieve him
by Drs. Betton and Moore. The strangulation had
existed between seventy and eighty hours.
As we were all united in opinion that no time was
to be lost, and as the patient consented to the opera-
tion, a dose of laudanum was exhibited, and, wdth the
assistance of my medical friends, I proceeded to per-
form it.
After making the usual incision through the integu-
ments, and taking up several small arteries, I came
down to the hernial sac. It was found to be thickened,
and contained no fluid. Here a difficulty arose ; and
much care was required to avoid wounding the parts
within the sac. It was soon ascertained, that the pa-
tient had an irreducible omental hernia, closely adher-
FROM INFLAMMATION. 57
ing to the sac. It required no little time and great
care to separate the adhesion and expose the omen-
tum. After this was accomplished, no intestine was
apparent, although the symptoms of strangulated
bowel were clearly marked. It was soon discovered
that there was a small but very tight stricture in the
hernial sac itself, not far from the abdominal ring.
This was divided by the aid of a small director and
bistoury. It was not until this was accomplished,
and the parts were unbound, that the real character of
the case was made to appear. The liberated omen-
tum was laid on one side, and a small portion of stran-
gulated intestine was exposed. But the difficulty had
not terminated even now, for the intestine was still
bound by a stricture at the abdominal ring, which I di-
vided with the blunt-pointed bistoury and director. The
intestine was inflamed, but not gangrenous. The omen-
tum was of a dark colour. I now reduced the intes-
tine without difficulty, and it was concluded that the
omentum should remain undisturbed. The wound was
dressed, and the patient put to bed. I left him under
the care of his medical attendants. He recovered
most happily, and called on me, not long afterwards,
in the city.
It occasionally happens that the inflammation which
occurs in the strangulated parts, produces adhesions
between the contents of the hernial sac, more particu-
larly in the vicinity of the stricture, and between the
folds of the intestine, which may prove a source of
difficulty in the operation. The following case is an
instance of this kind.
8
58 DIFFICULTY OF REDUCTION
CASE VII.
Strangulated Ventro-inguinal Hernia — Adherent Intes-
tine — Cure.
8th mo. 10th, 1834. I was called this afternoon by
Dr. George Uhler, to see M. G. a patient about seventy-
two years old, who has been under the care of Dr.
Uhler for about one year, with hydrothorax, and occa-
sionally slight ascites, wdth anasarca of the legs.
M. has been subject to hernia for twenty years, but
was always able to reduce it, until last night about 11
o'clock, when it became strangulated, and caused ex-
treme pain. Dr. Uhler was called to see him in the
night. Knowing the general condition of the patient,
he very properly declined the vigorous treatment some-
times adopted. He gave mild injections, one dose of
calomel and opium, and applied ice to the tumour. The
patient had two evacuations per anum soon after the
strangulation took place.
The tumour was on the left side — not very large —
it scarcely reached into the scrotum. The spermatic
cord could be distinctly felt in front of the tumour.
As the symptoms oLstrangulation were very clearly
marked, and urgent, it was my decided opinion, and
also Dr. Uhler's, that the patient would be subjected to
less risk from the operation than from active remedies,
which are at best uncertain; and after stating the case
fairly and fully to himself and family, and giving him
an opiate, he was placed on the table, and I proceeded
to the operation, assisted by Dr. Uhler and my pupil
Thomas, now Dr. Yardley.
FROM INFLAMMATION. 59
Several small vessels were divided and secured in
passing through the integuments. I came down upon
the sac in the usual way, and distinctly felt a fluid un-
der my finger; but I have seldom operated on a case
in which the sac was so much thickened. However, I
cautiously opened it, and brought the strangulated part
into view. It was intestine highly inflamed and par-
tially covered with a considerable portion of fresh
formed lymph, which I carefully removed.
I felt the stricture and divided it cautiously, with the
blunt-pointed bistoury, directly upwards, so that I
passed my finger by the side of the bowel. But, at this
stage of the operation, I was assailed by unusual diffi-
culties in consequence of the universal adhesion of the
intestine round the ring. I was compelled to dilate
more largely on this account, and, by means of my
finger, 1 detached the bowel all around, and endea-
voured to separate the adhesions in the duplicature of
the intestine itself: it was then introduced into the
cavity of the abdomen. Just at this moment, a small
quantity of yellow serum escaped from the wound,
which we concluded was a dropsical fluid. The patient
was returned to bed — his head was raised high, a large
bolster, doubled, was placed under his hams, and he
was directed barley-water, &c.
He bore the operation as well as could be expected.
As he seemed inclined to sleep, quietness was directed,
and the attendants were ordered, if he became restless,
to give him thirty drops of laudanum every six hours.
llth, morning, 11 o'clock. The patient has passed
an easy night; has had some singultus, but no vomit-
ing, and has passed no flatus. His abdomen is rather
tender on pressure but is not tense. Tongue moist.
60 DIFFICULTY OF REDUCTION
and slightly furred. Pulse 72, full and soft. Counte-
nance natural. Directed ol. ricini 5ss. to be taken
every four hours until the bowels are opened; also,
tine, opii gtt. xxx. every six hours, if restless; and for
diet, barley-water, rennet whey, molasses and water,
&c.
Evening, 7 o'clock. The patient complains of con-
siderable pain in the abdomen. He has taken sij. of
the oil, without having any evacuation. No flatus has
passed; there has been frequent vomiting and singultus.
There is no tension of the abdomen, but a slight sore-
ness on pressure. Pulse 72, rather full and soft. Tongue
moist and very little furred. Countenance natural. Di-
rected ol. ricini ^ss. every three hours, with occasional
injections of flaxseed tea. Diet and drinks continued
as before.
12th, morning, 10 o'clock. The patient has been rest-
less through the night, although he has taken thirty
drops of laudanum every six hours. He has taken two
ounces of castor oil since I last saw him, and has re-
ceived four injections, yet there has been no discharge
from his bowels, either of feces or flatus. Singultus
continues frequent. The abdomen is considerably tense,
and sore on pressure, wdth a burning sensation in the
bowels. Pulse 80. Tongue moist, and very little furred.
Countenance good. Vomiting frequent. Directed one-
fourth of a Seidlitz powder to be taken every quarter
of an hour, and the injections to be continued; the
laudanum to be omitted, and the same diet persevered
in. Evening, 6 o'clock. The patient has had several
discharges from the bowels, and is quite relieved of the
vomiting and singultus. The tension of the abdomen
has subsided, the burning sensation has ceased, and the
FROM INFLAMMATION. 61
soreness is much diminished. He has passed a com-
fortable afternoon. Pulse 75, and natural. Countenance
natural, composed. Tongue moist and nearly clean.
Directed the same quantity of Seidlitz powder to be
taken every hour, and the diet to be continued.
13th, morning, 8 o'clock. The patient has rested
comfortably through the night, and has had two dis-
charges from the bowels. Pulse, tongue, and counte-
nance natural. He is in every respect in the most
favourable condition. Directed the Seidlitz powder
every two hours. Diet continued.
14th, morning, 11 o'clock. The patient has passed
a pleasant night. He is in every respect free from any
apparent disease. The wound has nearly healed by the
first intention. There is no suppuration of the part.
The bowels are free. Directed the Seidlitz powder
every four hours.
15th, 12 o'clock. The patient's bowels have been
moved freely and naturally. He remains free from any
unpleasant symptom.
This patient recovered, although he had, during con-
valescence, an attack of intermittent fever, which was
then prevalent in his neighbourhood ; but he had ap-
proached the natural limits of human life, and died a
few months after the operation.
Thickening of the intestine, and an effusion of lymph
upon its surface without adhesions, are other results of
inflammation which deserve notice. In these cases it
is generally necessary to enlarge the first incision at
the ring, to allow the bowel to pass up. The lymph
should be cautiously removed by the fingers and the
handle of the scalpel. Cutting instruments should be
62 DIFFICULTY OF REDUCTION
carefully avoided in performing this part of the opera-
tion, as in the following case.
CASE VIII.
Inguinal Hernia — Strangulated, dark, and injlamed
Intestine.
4thmo. 9th, 1821. D. W., a man of colour, about
middle age, was admitted into the Pennsylvania Hos-
pital after 10 o'clock at night.
He had been subject to inguinal hernia on the right
side for several years, and strangulation had occasion-
ally taken place.
On this occasion the bowel had been strangulated,
as far as we could ascertain, between thirty-six and
forty-eight hours. The strangulation occurred in the
act of vomiting.
He had been visited this afternoon by Dr. Samuel
Tucker, who, on discovering the nature of the case",
called on me, and requested me to take charge of it.
No attempt at reduction had been made. When exa-
mined, the tumour was found rather large, and some-
what tender to the touch. There was but little tender-
ness of the abdomen; less, (according to the account
given by the patient,) than there had been soon after
the descent. The tongue was furred, but not dark co-
loured. The pulse was not active or tense. He had no
stool since the descent, had vomited after drinking, but
sometimes retained fluids for several hours on his sto-
mach.
FROM INFLAMMATION. ' 63
My colleagues, Drs. Hartshorne and Hewson, and
my friend Dr. Tucker, consulted on the case. Some
slight attempts were made at the taxis, and a purgative
enema was given, which operated on the rectum. But,
after stating the case to the patient, and obtaining his
consent, it was concluded to proceed at once to the
operation. Eighty drops of laudanum were given, and
a little before twelve o'clock, he was placed on the ope-
rating table.
On cutting down through the integuments and laying
bare the sac, it appeared to be distended with fluid.
On opening it in my usual way, with the forceps and
lancet, a bloody-coloured fluid issued out. I now en-
larged the orifice freelv, and laid bare the contents of
the sac. It contained a portion of bowel, without omen-
tum. The intestine was very dark coloured^ but there
were no adhesions, and the fluid in the sac ivas desti-
tute of the cadaverous smell. The intestine, moreover,
was much thickened by inflammation, and was coated
with a large portion of eflused lymph, particularly at
its lower and most dependent part. I removed a part
of this lymph with my fingers and the handle of the
scalpel. The bowel was also full of what I supposed to
be liquid feces. The stricture was at the abdominal
ring. I divided it, in part, upward, with the blunt-
pointed bistoury, and attempted gently to introduce the
prolapsed bowel, as 1 w as desirous of avoiding any un-
necessary enlargement of the ring. But as I was still
more anxious to avoid any violence to the intestine in
its inflamed state, I was under the necessity of enlarg-
ing the opening with the bistoury, and I then returned
the bowel.
The patient was placed on his back in bed, with his
64 •symptoms of stragulation
knees elevated, and a pillow under his hams; the wound
being previously drawn together by three stitches of
the interrupted suture, and adhesive strips. He was
directed to take barley-water, &c.
10th, mor7iing. The House-Surgeon sat up with the
patient, and reports that he passed a most excellent
night, and slept very well. I found him better than I
had reason to anticipate. His tongue is yet coated
with considerable yellow fur. His pulse remarkably
tranquil, considering all the circumstances. Directed
a table-spoonful of castor oil every three hours until the
bowels are opened.
This patient recovered completely in a short time.
SECTION VI.
SYMPTOMS OF STRANGULATION AFTER REDUCTION BY TAXIS.
In the section on the propriety of opening the her-
nial sac, cases have been referred to, in which symp-
toms of strangulation continued after reduction, and
terminated in the death of the patient. The issue of
these cases is ascribed to mechanical obstruction within
the sac, from a stricture at its neck, entanglement of
the omentum around the bowel, &c.
It is now intended to show, that a train of the most
alarming symptoms may continue for days after reduc-
tion, and yet may yield to appropriate medical treat-
ment.
The remedy upon which I have placed chief reliance
in these cases is mercury, introduced into the system
AFTER REDUCTION BY TAXIS. 65
in extremely minute portions. Calomel, in the dose of
one quarter or one sixth of a grain, given every one
or two hours, is the form I would recommend.
The efficacy of mercury administered according to
this method, has been tested by ample experience in the
treatment of many diseases. Dr. Ayre, in his work on
Marasmus, has thrown much light on this practice ; and
the former Dr. Edward Miller, of New York, who died
in 1791, has strongly recommended the practice in an
essay entitled " Remarks on the Cholera and Bilious
Diarrhoea of Infants." It is now much employed by
many physicians of Philadelphia, and is found appli-
cable to a great variety of diseases in which calomel
was formerly employed in larger doses.
I have carried out this practice to the treatment of
certain cases of strangulated hernia, with obvious ad-
vantage.
I shall not attempt to discuss at large the modus ope-
randi of this remedy. It is well known that calomel,
even in very small portions, has the power of correct-
ing functional derangement of the liver, and of exciting
the flow of yellow, healthy bile. That bile of this de-
scription is the most natural excitant of the bowels,
and is admirably calculated to promote steady and
healthful peristaltic action, it is presumed will be ge-
nerally admitted.
The introduction of calomel in such minute portions as
not to offend the stomach, or to produce any constitu-
tional irritation, is peculiarly appropriate in diseases
where the stomach is irritable, and in none more so than
in strangulated hernia. Large doses of calomel excite the
liver and alimentary canal to increased action, and thus
9
66 SYMPTOMS OF STRANGULATION
transcend that medium which it is so desirable to main-
tain: hence, while powerful doses are obviously injurious
in cases of recent strangulation, the accumulated effect
of minute portions, frequently repeated, may be attained;
while at the same time the irritability of the stomach
is allayed.
The following cases will illustrate the beneficial effects
of this practice.
CASE IX.
Hernia — Reduction by Taxis — Symptoms continued —
Stercoracious Vomiting — Recovery.
9th mo. 18th, 1835. Was called about 12 o'clock, M.
to see J. L., a respectable old gentleman residing in
Green street, in consultation with Dr. Janney. The
patient is a tall, spare man, of delicate constitution,
aged about sixty-eight j'^ears. He had been afflicted
with inguinal hernia of the left side, for between
forty and fifty years, during which time he had worn a
truss. Within the past few years, he has had several
attacks of strangulation. Dr. Janney has attended
him, and has succeeded in reducing the parts by taxis,
after venesection and a full dose of opium.
The present attack commenced on the night of the
13th inst.; he awoke from sleep, complaining of pain in
the groin, and discovered that the hernia was strangu-
lated. He went down stairs for the purpose of giving
himself an injection, and just before receiving it, had a
discharge from his bowels, in the privy, without produc-
ing any change in the tumour.
AFTER REDUCTION BY TAXIS. 67
He then took grs. ij. of sulp. morph. which com-
posed him for the night, and early the next morning he
was enabled to reduce the bowel. The symptoms of
strangulation, pain in the abdomen, vomiting, &c. still
continued, and on the 15th Dr. Janney was called. He
found the patient affected with copious mucous vomit-
ing, obstinate constipation, tympanitic and tender ab-
domen. On examining the groin, he could readily pass
the index finger through the internal ring, and there was
not the slightest appearance of a tumour externally, so
that he was convinced that the parts were returned.
He directed v.s. — and calomel gr. ss. every hour, with
carb.sod8e,and aqua menth. On the 16th, the calomel was
suspended for a short time, and calcined magnesia di-
rected in small and frequent doses; this was rejected by
the stomach ; ol. ricini was also tried, but was vomited
up ; the calomel was then resumed, and injections of
salt and flaxseed tea were given every three hours.
On the 17th he was attacked with stercoracious vo-
miting; the abdomen was tender to the touch; the
bowels, constipated. The calomel had been continued.
He was cupped on the abdomen, and bled from the arm
with relief — blood not sizy. The Doctor remarked that
the vomiting was first, mucous; secondly, dark-green;
thirdly, brown ; and fourthly, decidedly stercoracious.
On the 18th, I saw the patient in consultation. His
bowels were still confined, nothing having passed since
the night of the 13th; the stomach very irritable, he vo-
mited stercoracious matter twice while we were in the
room; pulse 112 in the minute, and irregular; tongue
brown and moist; abdomen slightly tympanitic, and
bears pressure very well. I could readily pass my finger
up to the internal ring, the spermatic cord evident;
68 SYMPTOMS OF STRANGULATION
skin warm and natural ; respiration easy ; countenance
not distressed; position in bed natural. Directed a
strong decoction of senna to be given as an enema
every three hours, and a poultice of stramonium leaves
to the abdomen.
Evening. One discharge followed injection ; it was
not preserved, but probably consisted of injecting mat-
ter only ; ring still more relaxed ; vomited but once
since our last visit. Directed calomel powder gr. 4 each,
one to be taken every hour ; and an injection of jalap
5J. to a pint of water, every three hours. Stramonium
leaves continued.
19th. Bowels have not been moved; sleep light and
disturbed ; vomiting less frequent, but still stercoracious;
pulse 135, and feeble; skin warm; tongue brown, moist,
and mucous, resembling very much the mucous tongue
in typhus fever, which I have always found to be asso-
ciated with great danger ; abdomen slightly tympani-
tic, abdominal muscles seemed relaxed, the folds of the
intestines can be distinctly traced underneath the mus-
cles ; ring still more dilated, the finger can be passed
an inch within the abdomen. Has taken calomel
powders regularly through the night, and at his own
request, has been placed in a warm bath ; has had three
injections of jalap, without effect. Same treatment con-
tinued, with the addition of a powerful injection to be
thrown in through a tube passed beyond the sigmoid
flexure of the colon.
Evening. Dr. Janney and my son succeeded in pass-
ing a large gum elastic tube about thirteen inches up the
bowel, through which ^iij. of jalap, suspended in a large
quantity of flaxseed tea, was injected. During their
visit, about 12 o'clock, the hernia descended into the
sac, and was readily returned. Has passed several por-
AFTER REDUCTION BY TAXIS. 69
tions of the injection without foeccs, stercoracious vo-
miting continues, pulse 112. He says there is a sHght
rumbling in the bowels, and that he feels rather better.
Continued small doses of calomel, and poultice of stra-
monium leaves.
20th. Patient thinks that he cast up the fluids which
have been injected per anum; says he has passed flatus,
and believes his bowels have been moved ; has had se-
veral dark-coloured evacuations, which we suspected to
be nothing more than coloured mucus. Stercora-
cious vomiting continues unabated; pulse 128; skin
warm; slept at intervals through the night; says he feels
rather more comfortable ; rises from bed with ease ;
slight tenderness of the abdomen. Calomel powders
continued. Directed warm bath, an injection containing
ten drops of croton oil into the rectum, and another
injection of jalap by the tube into the colon.
Evening. Has had no discharge, though there is evi-
dently more motion in the bowels, pulse 120, expression
of countenance more lively ; has taken portions of
chicken-water through the day, which he relished;
asked for boiled meat ; thinks his strength is improv-
ing. Had an injection into the colon of Sss. of jalap
suspended in mucilage. Continue powders. Directed
an anodyne enema at bed time.
21st. Patient much better. We were informed that
soon after we left him on the preceding evening, he had a
copious bilious discharge, which was preceded by con-
siderable rumbling in the bowels, and was followed by
several more in the course of the night. We inspected
the discharges, and were fully satisfied that they were
feculent. Has had no vomiting since the bowels were
opened, slight ptyalism was observable, pulse calm and
70 SYMPTOMS OF STRANGULATION
natural, tongue moist and brown, probably coloured by
tobacco, which he has been chewing this morning for
the first time during his illness ; has no pain, feels an
appetite. He took an anodyne enema, and slept com-
fortably through the night. We suspended medicine,
and directed mild nutritious drinks.
22d. Still improving — had a copious stool in the
course of yesterday, and one this morning; abdomen
perfectly flaccid; suffers no pain; dressed himself and
went down stairs yesterday; ring contracted to its
usual dimensions. Directed a tea-spoonful of magnes.
calc. every three hours until it operates.
23d. Medicine has operated several times, feels quite
well, except that he is weak. Convalescent.
27th. Feels himself quite well, is dressed and walk-
ing about, and has resumed his usual habits.
RemarJcs.
This case affords ample room for reflection and re-
mark. In it we. are presented with a train of the most
dangerous syhiptoms, especially stercoracious vomit-
ing, which continued for several days ; and though the
patient was an old man of delicate constitution, yet he
finally recovered.
In reviewing the practice pursued, I am disposed to
believe, that the minute doses of calomel had an im-
portant agency in the cure.
The steady application of stramonium leaves over
the whole abdomen, combined with the use of powerful
injections, as used in a case reported by Dr. Condie,
hereafter to be detailed, although it is derived from an
" African colic doctor," is rational and worthy of imi-
tation. Every practitioner is familiar with the dilating
AFTER REDUCTION BY TAXIS. 71
power of the extract of stramonium over the iris, and
in this case the poultice certainly did appear to dilate
the abdominal rinor.
It will be noticed, that this patient had been re-
lieved several times from strangulated bowel, by exhi-,
biting a large dose of opium after the use of the lancet.
Dr. Janney has related to me several instances of re-
markable success from this plan, which has occurred in
his practice. He administers from 3 to 4 grs. of opium
at one dose, and considers it very important that a large
dose should be given at a time, instead of giving it in
small portions, as is frequently done. Should a fair case
of recent strangulation present itself, I should pursue
this course, with the addition of a poultice of stramo-
nium leaves, before proceeding to the operation.
The following case, which has been kindly furnished
me by Dr. J. Rodman Paul, bears a striking analogy
to the preceding.
CASE X.
On the 12th of November, 1833, Dr. Neill requested
me to accompany him to visit Mr. Steinhaur, a baker,
residing in South Second street, who was labouring
under strangulated inguinal hernia of the right side.
Various means for its reduction had been resorted to
without success, and the pain which the patient expe-
rienced, together with the incessant vomiting, induced
us to propose an immediate performance of an opera-
tion, should another effort of taxis prove unavailing.
Fortunately, in this attempt we succeeded; the bowel
72 SYMPTOMS OF STRANGULATION
was returned, and we were enabled to push the finger
covered by integument, through the abdominal canal
and rings into the cavity of the abdomen. In this con-
dition we left him, auguring a diflerent state of things
^at our next visit. But we were disappointed, the vomit-
ing continued, and the bowels remained obstinately
constipated ; purgatives were either rejected or pro-
duced no effect; injections into the colon through a
gum elastic tube were attended by no better result.
This case reminded me strongly of one that came under
my care when a resident at the Pennsylvania Hospital.
It was that of a coloured man who was operated on for
strangulated hernia by Dr. Parrish, and in which the
symptoms continued unrelieved after the operation, until
the gums were touched by the use of small doses of
calomel. The same plan was now pursued in Stein-
haur's case, and with the same happy result; for as soon
as the peculiar effect of the mercury was produced, the
constipation yielded, and the vomiting ceased, it being
ten days from the commencement of the attack.
SECTION VII.
SYMPTOMS OP STRANGULATION AFTER OPERATION.
Even after the surgeon has performed the operation
for strangulated hernia to his entire satisfaction, he
sometimes meets with disappointment. The contents
of the sac may be exposed, and may present a promis-
ing appearance, the stricture may be liberated, and
the parts returned without difficulty into the abdo-
AFTER OPERATION. 73
men, yet day after day may pass over, without any im-
provement in the condition of the patient. From some
unknown cause the obstruction in the bowels is kept
up, and death is threatened if rehef is not afforded.
The following case affords a striking instance of
this kind:
CASE XI.
Scrotal Hernia — Symptoms of Strangulation after opera-
iio7i — Cure,
ll//i mo. 12th, 1825. W. C, an old coloured man,
was admitted this morning into the Pennsylvania Hos-
pital. He has been afflicted for many years with a large
scrotal hernia of the right side, and has had several
attacks of strangulation, but the parts have always
been returned without an operation. About 11 o'clock
last night the hernia became again strangulated.
On the present occasion, the warm bath, the tobacco
injection, bleeding ad deliquium, cold applications, &c.
were tried without effect. An opiate was then given,
the operation was proposed, and the patient con-
sented.'
His stomach was irritable, and he vomited violently
as he was carried to the operating room. His abdo-
men was very tumid and tender to the touch, as was
also the tumour. About 8 o'clock in the evening, assisted
by my friend and colleague Dr. Hewson, and in the pre-
sence of the class of students, and many professional
visitors, I proceeded to the operation ; the patient hav-
ing previously taken three grains of opium.
10
74 SYMPTOMS OF STRANGULATION
I made a free incision, commencing above the exter-
nal ring, and extending nearly to the bottom of the scro-
tmn, then dissected down to the sac, and laid it open in
the usual manner. At the external ring a firm stricture
was detected, which was carefully divided with the
blunt bistoury, until T could pass the finger by the side
of the bowel into the abdomen.
Just at this moment a most unpleasant circumstance
occurred — the patient w as seized with violent vomiting.
Notwithstanding my eflforts to prevent it, a portion of
intestine considerably larger than that which was in-
volved in the stricture, was forced out of the abdomen.
The straining and violent bearing-down efforts were
such, that I could not return the parts until I had di-
lated the ring more freely ; even then it was with the
greatest difficulty that I succeeded at all. After the
reduction, a branch of the external pudic artery, which
bled considerably, was secured by a ligature.
The patient complained greatly during the operation,
and on every attempt at reduction, he cried out, re-
ferring the pain to the umbilicus.
The dressing being completed, he was placed in bed
with his limbs supported on the angular box and pil-
low. The belly continued tense, painful on pressure,
hard, and tympanitic. He took two grains of opium at
half past 9 o'clock, one grain at half past 12, and an-
other at about three in the morning ; the last was re-
jected. He was ordered to take no other drink or
nutriment than barley-water acidulated with lemon-
juice.
13th. The patient had several slight attacks of hiccough
after the operation, but has passed a quiet night, dozing
frequently. Pulse 80, skin nearly natural, tongue furred;
AFTER OPERATION. 75
he has passed neither flatus nor feces. He complains,
occasionally, of a sharp pain around the umbilicus.
The abdomen is still tense and tympanitic. Ordered
ol. ricini 3ss. every two hours until purged ; also opii.
gr. j. every four hours, if restless. Regimen continued.
Evening. Pulse 80, full and soft ; abdomen less tender
to the touch ; stomach retentive. The patient is dis-
posed to sleep. He has occasionally very slight singul-
tus. He has taken about an ounce of the oil, but seems
to suffer for want of a free discharge from the bowels.
An injection afforded partial relief Dr. Parrish or-
dered injections of warm w ater to be thrown up through
a large flexible catheter, and some fecal matter and
flatus were thus brought away. Dry syringing with
the same instrument was then employed, with some re-
hef to the flatulent distension. He has passed his urine
freely. Ordered to continue the oil, and also the dry
syringing, if necessary.
14th. The patient took last night a dose of opium,
in consequence of pain in the abdomen, and not being
relieved, warm fomentations were applied. The abdo-
men is still tense and tender ; pulse 80 ; tongue furred
and moist. He seems disposed to doze ; some flatus
has been passed this morning. Ordered injections of
strong senna tea, the castor oil being continued ; and
if these should fail to operate on the bowels, croton oil
gtt. ss. to be given every hour, until four drops be
taken. — Evening. His condition remains much the
same. No evacuation has taken place. His stomach
is retentive, but he has frequent eructations. Ordered
to continue the same remedies. The croton oil increased
to gtt. ss. every two hours. An opiate to be exhibited
when the patient is restless.
76 SYMPTOMS OF STRANGULATION
15th. Pulse 80; skin natural; tongue moist, furred,
and rather more yellow ; countenance depressed ;
spirits low ; abdomen very tense and tympanitic. The
patient has passed a little flatus without the tube, but
has had no stool. A dose of terebinthinate mixture was
exhibited, but the stomach rejected it immediately.
Ordered one-fourth of a grain of calomel to be taken
every half hour ; fomentation of spirits of turpentine
to the abdomen ; and, if restless, injections of assafcE-
tida, each containing a drachm of laudanum ; also
directed to drink chicken-water. — Evening, His con-
dition continues the same, except that there is more
tenderness of the abdomen. Ordered the calomel to be
given in the dose of one or two grains every hour if the
stomach will retain it. If not relieved, a hot brick and
spirits of turpentine to be applied to the abdomen. Ano-
dyne enemata to be given if required.
16th. Pulse 80; abdomen less tense and tender;
tongue furred and moist ; temperature of the skin natu-
ral. The patient has taken, in divided doses, about
twenty-five grains of calomel without effect. He has
had singultus during the night and morning. An ano-
dyne enema and the stimulating fomentations have
partially relieved his hiccough. Treatment continued.
Evening. Pulse 68, full, round, and soft. Abdomen tym-
panitic, but less tender. The singultus continues, but
the patient says he feels more comfortable than at any
other time since the operation. There has been no fecal
discharo^e. Ordered to continue the calomel, and if
much pain occurs, the anodyne enema.
17th. Early in the morning, the patient complained
of occasional violent pains, beginning in the wound
and extending all over the body, up to the throat. The
AFTER OPERATION. 77
pain about the Avound was as severe as before the ope-
ration. Half past 9 o'clock — pulse 80, full, round and
rather tense ; temperature of the skin increased ; pain
still sreat ; sinaultus continues ; abdomen less tense.
As the pain appeared to increase with the vascular ex-
citement, Dr. Parrish ordered him bled to the amount
of twelve ounces. Ordered also the warm bath, and
occasional purgative enemata. The anodyne injec-
tions, and the calomel to be continued. — 12 o"^ clock.
Pulse 84 ; tongue and skin unaltered; he has been in the
warm bath fifteen minutes ; again bled to the amount
of sixteen ounces. — Evening. Tongue still moist ; pulse
88, firm, and full ; singultus continues ; the w^arm bath
has been repeated ; this, and the venesection have given
him much relief. Treatment continued.
18th. The patient has passed a tolerably good night ;
free from pain, though much troubled with singultus ;
the warm bath was repeated at 9 o'clock last evening
with great benefit ; pulse 84, furred and moist ; skin
natural ; fulness and tension of the abdomen diminished,
and no pain felt on pressure. He says he is much re-
heved, but has had no fecal discharge ; flatus is passed
occasionally ; ordered to omit the calomel. R. pulv.
jalap, oi. supertart. potass ^ij. m. div. in pulv. no. 6.
One of these powders to be given every hour, in sweet-
ened mint-water. — Evening. The patient has been
once in the warm bath, and has taken four powders ;
pulse 80. His condition remains, in other respects the
same ; ordered to continue the powders, and the ano-
dyne injections when necessary.
19th. Pulse 72, nearly natural ; skin natural ; tongue
furred and moist ; abdomen as yesterday ; constipation
and singultus continue j vomiting frequent in the night ;
78 SYMPTOMS OF STRANGULATION
the calomel was resumed this morning ; countenance
good ; ordered to continue the calomel and occasional
warm bath ; mutton broth directed for his diet. — Even-
ing. The patient feels a little better : in other respects
his condition remains the same. He has partaken
freely of his mutton broth, which he enjoyed much.
Treatment continued.
20th. Pulse 78 ; tongue less furred, quite moist, and
somewhat redder ; gums more tumid ; abdomen still
tense but softer ; singultus abated ; countenance and
spirits good. The patient discharged flatus several
times, but no feces ; he rehshes, and desires food. —
Treatment continued. — Evening. Pulse 72 ; a good
deal of flatus has been passed, and the patient is dis-
posed to renew his old habit of chewing tobacco.
Treatment continued.
21st. The patient has had several fecal discharges.
Pulse 64 and soft ; gums slightly sore; abdomen greatly
diminished, and its uneasiness relieved ; singultus still
occurs occasionally. The first alvine discharge took
place last night about 10 o'clock ; he then began to
take sulphate of magnesia §ss. every three hours ; or-
dered to omit the calomel and continue the salts. —
Evening. He has had four evacuations since morning ;
some singultus continues. Every appearance is fav-
ourable.
22d. Pulse 64, full and soft ; abdomen becoming soft
and natural ; appetite good ; the patient has had free
discharges from the bowels ; there is still a little sin-
gultus. The sac and neighbouring integuments are
very considerably thickened by inflammation, which ex-
tends along the whole length of the incision.
From this date the patient was regularly convales-
AFTER OPERATION. 79
cent, suffering little except from singultus, which was
relieved by anodyne enemata containing a portion of
the oil of amber, and the musk julep, administered in the
proportion of five grains of musk in each dose. He
was discharged in good health, on the thirtieth of the
month ; the cicatrization of the wound being nearly
completed.^
*
* It will be perceived that the preceding case is unusually interesting.
The patient was in extreme danger, and eight days elapsed after the opera-
tion before the bowels were opened. Its details may be regarded as pro-
lix, but I have deemed it proper to give it in its present form as it was re-
ported at the time by my former pupil Dr, J. Rodman Paul. He was then
house Surgeon in the Pennsylvania Hospital ; his humane and unremitted
exertions in the case of a very humble, yet truly deserving man, while it
merited and received my warm approbation, has been, I doubt not, amply
rewarded by the consciousness of having discharged his duty.
CHAPTER III.
DIAGNOSIS OF MORTIFICATION.
SECTION I.
ON THE CONSTITUTIONAL EVIDENCES OF MORTIFIED BOWEL.
It is deemed a point of great importance amongst
surgeons to have some unequivocal evidence, of the
existence of mortification in a strangulated bowel, be-
fore it is exposed by an operation. It is highly
desirable, in forming an opinion of the probable result
of a case, in which an operation is proposed, that the
surgeon should present to the patient and his friends,
a full and candid view of the whole subject. If there
is ground for the belief that the incarcerated parts, or
a portion of them, are actually dead, the prospect of a
successful issue is necessarily limited ; hence, it be-
comes very important to estimate the value of those
signs which are laid down for our guidance in these
cases, and to be cautious in pronouncing a positive
opinion. To hold out a flattering prospect of success
when it cannot be founded on a proper share of rea-
sonable evidence, I consider radically wrong. The
symptoms denoting mortification of the bowel, as com-
monly detailed in systematic works, are not in my judg-
ment sufficient to establish the fact.
CONSTITUTIONAL EVIDENCES OF MORTIFIED BOWEL 81
Thus, we are taught to beheve that when the bowel
becomes mortified, the pain ceases ; the pulse which
has been active, is feeble and creeping; clammy
sweats and a death-like coldness pervade the sur-
face ; the countenance becomes hippocratic ; singultus
and stercoracious vomiting are generally present, and
the patient dies with the intellect perfectly clear.
That these symptoms are present in a large majority
of cases in which mortification of the bowel has taken
place, experience amply shows ; I have, however, seen
cases in which extensive mortification has existed
without the occurrence of these symptoms, and others
in which the usual symptoms of mortification were
present without the bowel being actually dead, as has
appeared on the performance of the operation.
As an example of the former condition, I will state
the following cases :
CASE XII.
Strangulated Scrotal Hernia — Gangrene — Death.
Itli. 7no. 14th, 1814. A mulatto man who appeared
to be about thirty years of age, was admitted into the
Philadelphia Almshouse on the evening of this day,
with strangulated scrotal hernia.
15th. I visited him in the morning, and called a con-
sultation on the case, as the usual remedies for reduc-
tion had been tried in vain. The operation was per-
formed in the afternoon, being three days after the
commencement of strangulation ; the patient had not
had a stool from the time of the accident. Just
11
82 CONSTITUTIONAL EVIDENCES
before the operation, the condition of his pulse, skin,
and tongue was such as would not have induced the
suspicion of gangrene ; his abdomen was tumid and
painful to the touch. He had some hiccough and
vomiting.
I operated in consultation with my medical friends,
Drs. James, Hewson, Hartshorne, Chapman, and Stew-
art. No difficulty presented in the course of the ope-
ration, but in laying open the hernial sac, it was found
that a portion of intestine only, was contained in it,
and the most depending part of the bowel was morti-
fied for the space of about half an inch in width and
two inches in length. The stricture was at the ab-
domnial ring, and embraced the bowel very closely ; it
was divided with the blunt-pointed bistoury, and the in-
testine left in the wound. We directed bladders of
warm water to be kept constantly applied to the wound ;
barley-w^ater for drink and nourishment, and also, ol.
ricini. §ss. every two hours.
16th. The patient passed the fore-part of the night
pretty well, probably in consequence of two grains of opi-
um which he had taken before the operation ; but he had
pain this morning about the umbilicus, recurring at short
intervals. He took four doses of oil during the night,
but rejected them in the morning by vomiting. He has
had no discharge from the bowels, but has passed flatus
repeatedly. His stomach is irritable, and through the
dav he has had singultus. It was concluded this morn-
ing to make an incision throughout the whole extent of
the mortified part. I did it with a scalpel. Some liquid
feces escaped, but the quantity was very small, and I
began to fear that there was still some internal stricture
which prevented the evacuation of the bowels. After we
OF MORTIFIED BOWEL. 83
left him this morning, hquid feces flowed freely, and re-
lieved the pain at the umbilicus. This evening he has
a preternatural coolness of the skin and clammy sweats,
which make me uneasy about him ; he has, also, sin-
gultus. My friend Dr. Hcwson saw him with me. The
patient says he is much relieved, and perhaps his pre-
sent state arises from exhaustion. The appearance of
his tongue is not bad. When the abdomen is pressed,
it feels painful. Directed a very large blister to the ab-
domen; also porter and water for drink, and if restless,
a dose of opium to be given.
17th. The blister appears to have had a very happy
effect, and the condition of the patient is evidently im-
proved. His pulse is better, his skin warmer, and the
discharges from the artificial anus very copious. Or-
dered him to be kept on a light, liquid diet.
18th. The patient continues to improve. He has had
copious discharges from the opening in the bowel, and
has also had a stool per anum. Treatment continued.
19th. The patient still continues to improve, and says
he is quite hungry.
The patient continued to improve pretty regularly ;
the mortified parts sloughed very kindly, and healthy
pus formed in the divided parts. The discharges from
the bowels were free at the artificial anus ; the tension
of the abdomen subsided entirely, and we began to flat-
ter ourselves that the danger was over. But we were
disappointed in our hopes. He had, it will be recollected,
on the evening of the 1 6th, a coolness of the skin, &c.
which soon went off". Several times after this, I found
him low-spirited and languid, but he was always relieved
by the tincture of assafoetida, and Hoflhian's anodyne,
given in small and frequent doses. He had, also, chicken
84 CONSTITUTIONAL EVIDENCES
and mutton broth, which appeared to suit him very
wel].
On the evening of the 24th inst. the senior pupil of
the house v^^as alarmed at finding him in a very low
state, and with an irritable stomach. His pulse had
fallen, and his skin was cold and clammy. Various
efforts were made to revive him, but without effect.
I saw him on the morning of the 25th, sinking
rapidly. Every effort to rouse his system failed. A
more than deathly coldness pervaded the surface of his
body, which was bedewed with sweat. Respiration was
extremely laborious, and appeared, toward the last, to
be performed entirely by the intercostal muscles.
Pressure on the abdomen gave no pain. The tongue
was moist. He died about 1 o'clock, P. M.
It is worthy of remark, that on the afternoon of the
24th he was sensible of a gradual decline of strength
in all the muscles of voluntary motion, and it appeared
as if a complete paralysis occurred, previously to death,
in the lower and upper extremities.
Dissection.
In the presence of my friend Dr. Hewson, and a num-
ber of medical pupils, I examined the body on the fol-
lowing day.
On laying open the abdomen, no adhesions were found
among the intestines generally, as in peritoneal inflam-
mation. The portion of intestine included in the stric-
ture was a part of the ileum, about eight or ten inches
before its termination in the cmmm. The strictured
part adhered, very firmly, to the parts about the ring,
and from the superior portion it appeared that inflam-
mation had extended itself a considerable distance
OP MORTIFIED BOWEL. 85
along the tube ; but it seemed to have been of a low
grade, and had passed into a state of gangrene, without
adhesions being formed beyond the part immediately
involved in the stricture.
To illustrate the truth of the second position, viz.:
that the constitutional symptoms of mortification may
exist, when the incarcerated bowel is not in a sphace-
lated condition, the following case is presented.
CASE XIII.
Strangulated Femoral Hernia — Deceptive Symptoms of
Gangrene,
1th mo. 2d, 1818. I was called in the afternoon, to
the Widows' Asylum, by Dr. Sargent, to see an old
woman who had been labouring under strangulated
hernia since the evening of the 29th ultimo.
Dr. Sargent was called to her yesterday, and at-
tempted the reduction of the parts by taxis. The patient
had been freely bled from the arm, was placed in a
warm bath, had received several purgative injections,
and ice was applied to the tumour. This morning she
was again bled, and a tobacco enema was administered,
which produced great nausea and sickness, but without
effect upon the tumour. She was removed to the Hos-
pital.
My friend Dr. Hewson saw her with us. We found
her entirely free from pain in the tumour or abdomen^
though it had been severe from the commencement of
the attack. The pulse was very feeble, the skin cool,
86 CONSTITUTIONAL EVIDENCES
and she was affected with singultus. The whole aspect
of the case induced us to suspect that the intestine was
mortified. An immediate resort to the operation was
advised as the only alternative ; and, after administer-
ing a full dose of laudanum, I proceeded to perform it,
assisted by Drs. Hewson, Hartshorne, and Dorsey, and
in the presence of Dr. Sargent and others.
The tumour lay below Poupart's ligament. It was
of an oval figure, being situated across the groin. I
made a crucial incision over it, and dissected up the
corners, cutting the fascia with the silver director and
the bistoury, until the sac was exposed. This w as care-
fully opened, and freely divided. A small quantity of
bloody serum escaped, hut it was destitute of the cada-
verous odour. The sac contained a small portion of in-
testine, of a very dark mahogany colour, resembling
very much a mortified bowel ; hut yet it was concluded
to return it.
I next divided a small stricture in the sac itself. In
passing the finger inward, in the direction of the spine
of the pubis, to discover the seat of the stricture at the
ring, I thought I perceived, rather indistinctly, a slight
arterial pulsation. My colleagues were of the same
opinion. At this moment the pulse at the wrist was
very low, hardly to be perceived, and the artery was no
doubt influenced by the same cause.
I proceeded with great caution in dividing the stric-
ture. By pushing my finger in the direction of the femo-
ral arch on the pubic side, I was enabled to hitch up
the lower edge of the tendon on my finger nail. The
blunt-pointed bistoury was introduced along side of the
finger up to the stricture, and a very small portion was
divided. This enabled me to push forward the finger a
OF MORTIFIED BOWEL. 87
little further, keeping it in advance of the point of the
bistoury, carefully feeling for the pulsation, until ano-
ther slight cut was made; thus by enlarging the opening
gradually, I was at last enabled to pass my finger into
the cavity of the abdomen by the side of the strangu-
lated bowel, and thus reduced the protruded parts with
safety.
The patient lost but little blood during the operation,
though she was exceedingly exhausted. We gave her
a draught of wine and water, and put her immediately
to bed. The pulse was very low, and the skin cool and
clammy. The operation was completed between seven
and eight o'clock in the evening.
On visiting the patient at 10 o'clock at night, I found
her better than I had anticipated. The pulse was con-
siderably elevated, and the temperature of the skin was
more natural. I directed barley-water for nourishment,
and laudanum, at short intervals, if restless. The bowels
had not been moved, but the stomach was settled.
3d, Morning. The patient has passed a good night;
is free from pain ; her pulse continues better ; her sto-
mach retentive ; tongue furred ; abdomen tumid, but
not tender to the touch. She has had no evacuation
from the bowels. — Evening. In the course of the day
she had a mild laxative enema, which was followed by
copious fecal evacuations. The belly is less tumid and
without preternatural tenderness. The tongue is furred
and moist. The patient has been kept principally on
barley-water since the operation. Her pulse is fuller,
but not active.
4th. Morning. Every thing is going on well. The
patient has passed an easy night ; her tongue is clean-
ing rapidly. She is very desirous of something to eat»
88 CONSTITUTIONAL EVIDENCES
I directed runnet-whey to be added to her diet. — Even-
ifig. Still doing well. She has some disposition to dis-
charge from the bowels, without being able to effect it.
Abdomen tumid, but soft. I directed a mild injection.
This case went on without any unpleasant symp-
toms ; the parts healed kindly, and the patient was dis-
charged, cured.
The following case, which forcibly illustrates the con-
dition of which we are treating, was kindly furnished
by my friend Dr. Condie. I was called to see the pa-
tient in consultation with Dr. C, and considered, with
him, that the case was entirely beyond the reach of
human skill. I have rarely seen a recovery from a situ-
ation so discouraging.
CASE XIV.
Strangulated Femoral Hernia — Apparently mortal symp-
toms — Keduction by Stramonium.
M. Y., a female about fifty years of age, of robust
frame and temperate habits, had been for some time
affected with a reducible femoral hernia of the left side.
On the 10th of October, 1832, while the patient was
engaged in some laborious occupation, the hernia be-
came suddenly strangulated.
I saw her on the morning of the succeeding day. The
hernial tumour was about the size of a goose's egg. The
patient complained of acute pain extending from the
left groin to the anterior part of the abdomen, which
latter was considerably swollen, and tender to the touch.
OF MORTIFIED BOWEL. 89
There was considerable febrile excitement, with a tense,
quick, and frequent pulse, and considerable nausea.
The bowels had not been evacuated since, nor for some
time preceding the strangulation. As the slightest
pressure on the hernial tumour caused very great suf-
fering to the patient, it was impossible to attempt, at this
period, its reduction by taxis. Eighteen ounces of blood
were taken from the arm, a purgative injection was
administered, and compresses wet with cold water di-
rected to be kept constantly applied upon the tumour.
In the afternoon I found the patient greatly relieved.
The pain was less intense; the tenderness and tume-
faction of the abdomen were diminished ; and the pulse
was softer, more developed, and less frequent. So far
as the obstinacy and prejudices of the patient would
permit, an attempt was now made to reduce the hernia
by taxis and the usual accessary means, but without the
desired effect. The cold applications to the tumour
were directed to be continued, and the injection to be
repeated — the former one having produced no effect on
the bowels.
During the night the pain returned with increased
severity, and the tenderness of the abdomen was such
as to render the weight of the bed-clothes intolerable.
No discharge had taken place from the bowels. The
pulse was contracted and extremely frequent ; the sur-
face of the body was cool and dry. The slightest touch
applied to the hernial tumour was productive of great
distress to the patient. Ten ounces of blood were taken
from the arm; leeches to the tumour were directed, but
not applied ; the injection was repeated, and the cold
applications continued.
The more urgent symptoms were somewhat abated
12
90 CONSTITUTIONAL EVIDENCES
on the ensuing day. The countenance of the patient,
however, evinced very great suffering. She remained
constantly on her back, with her thighs drawn up to-
wards her abdomen. Some degree of dehrium was
evinced in the evening. The bowels had not been
opened. But httle was done in the way of treatment.
The patient was extremely ignorant and prejudiced, and
obstinately opposed whatever was advised. The danger
of her case was clearly stated to her, and the propriety
of a surgical operation was repeatedly urged ; but " to
being cut up alive," as she expressed it, she declared
she never would consent, whatever might be the re-
sult.
On the morning of the 12th I was sent for in great
haste. I found the patient in a state of great prostra-
tion, with a small, feeble pulse; cold, clammy skin; con-
tracted features ; and throwing up from the stomach,
at intervals, a dark green fluid. She complained of very
little pain, excepting when the abdomen, or hernial tu-
mour was pressed upon. The latter, which had been
previously tense and elastic, had now a somewhat
doughy feel. The vomiting of green fluid was suc-
ceeded, in the course of the morning, by discharges
from the stomach of fecal matter in considerable quan-
tities.
The patient now expressed a wish that Dr. Parrish
might be called in. This wish was immediately com-
plied with, and the doctor attended in the afternoon,
accompanied by his son. The features of the case were
now, in our opinion, such as to render all chance of re-
covery utterly hopeless ; and I am convinced that any
medical man would have concurred with us in this
opinion had he examined the prostrate condition of the
OF MORTIFIED BOWSL. 91
patient — the cold, clammy skin — the feeble, and almost
extinct pulse — the sunken and contracted features —
and the fecal vomitins:.
It was decided that from an operation under such
circumstances, but little benefit could be expected: — it
was agreed, however, to give the patient this doubtful
chance of relief, provided that, after a candid statement
to her, of our views of the case, she should request it.
She, however, positively refused to submit. It was
agreed, on separating, that I should inform Dr. Parrish
in the morning, of the condition of the patient.
On calling the next morning to see the patient, I
found her still alive, and that she had called in a black
man, celebrated in the Neck, {the low country south of the
city,) as " a curer of ruptures" both in men and in cattle.
I remained, being somewhat curious to watch his pro-
ceedings. The hernial tumour he had covered with
a poultice of bruised herbs — the leaves, so far as I could
judge by the smell, of stramonium — and he was prepar-
ing an infusion of herbs to be used as an injection.
This infusion was evidently of senna leaves. The in-
jection he proposed to administer every fifteen minutes,
by means of a very large and very powerful syringe.
He spoke confidently of the successful result of the
case.
I saw the patient again on the following morning, and,
to my utter astonishment, found her in a tolerably com-
fortable condition ! The hernia was reduced ; all the
alarming symptoms, under which she had laboured on
the preceding day, were gone ; and, though extremely
weak, she was evidently in a fair way of recovery ! I
learned, that after continuing the injections for nearly
two hours, there occurred a copious evacuation from
92 • CONSTITUTIONAL EVIDENCES OF MORTIFIED BOWEL.
the bowels, of a number of hard balls ; and that then,
suddenly, the tumour had disappeared with a gurgling
noise. These balls had been preserved for my inspec-
tion — they were formed of hard, dark-coloured feces, of
different sizes, from that of a pea to that of a pistol
ball, or even larger.
The patient continued daily to amend, and at the ter-
mination of ten days from the reduction of the hernia,
was seen by me sweeping off her door!
Sept. 19th, 1835. I saw her this day. She enjoys ex-
cellent health, and so far as I am able to say without
an actual examination, is radically cured of her hernia!
In forming an opinion of the probable result, in a
case of mortified bowel, it becomes necessary to con-
sider the astonishing variety in the human constitution,
and its ability to resist, or its disposition to yield to the
operation of mechanical causes, from which it is unable
to escape. The powers of this vis insita in different
constitutions, cannot be estimated by any known stand-
ard. It is unmeasurable and unknown until it is sub-
jected to trial. Thus, in some constitutions, a very
small portion of bowel may become strangulated, and
in a few hours, its death may be effected, and all the
alarming symptoms of mortification may ensue ; while
in others, mortification may exist for days, without pro-
ducing the symptoms that usually mark its presence.
*
PROOFS OF MORTIFICATION ON OPENING THE SAC. 93
SECTION II.
ON THE PROOFS OP MORTIFICATION ON OPENING THE SAC.
A careful examination of this part of our subject be-
comes necessary. The treatment to be adopted in the
event of mortified bowel, differs most essentially from
the practice required for strangulated parts in a living
state. If, unhappily for the patient, the surgeon should
mistake an inflamed, for a sphacelated intestine, and in
an incautious moment, should lay it open by a free in-
cision, he inflicts a wound which may prove fatal.
Even if the patient should escape with his life, it is at
the imminent peril of an artificial anus, which, under
some circumstances would scarcely be. preferred to
death itself.
Persons who have derived their information on the
signs of mortification from systematic works on sur-
gery, may consider them so clear that they cannot be
mistaken. They may regard it as a work of superero-
gation to prove that which is self-evident ; but those
who have encountered the difficulties of forming an
opinion on this point, at the bed-side of the patient,
will excuse me for dwelling for a few moments on this
topic.
The colour of the intestine is generally regarded as
one of the strongest evidences of mortification. If the
bowel present a dark and deep purple, approaching to
black, and if circulation be wanting in the part, it may
be pronounced dead. In order to ascertain whether
the circulation has really ceased, it has been recom-
94 PROOFS OF MORTIFICATION
mended by some surgeons, that firm pressure with the
finger should be made upon the suspected part, and if
the colour remains unchanged, it may be considered in
a sphacelated state. I freely admit that a dark purple
colour, and an absence of circulation, are observed in
cases of real mortification, arising from a loss of vitality
in the blood-vessels, and from the consequent coagula-
tion of the blood. But I fully believe that this condi-
tion may arise from the mechanical operation of the
stricture, without the integrity of the bowel being seri-
ously injured. As a familiar illustration of this fact,
we may refer to the simple experiment of tying a string
firmly round the extremity of a finger, thereby arrest-
ing the circulation beyond the string, and producing a
dark blue or purple colour in the part. The same prin-
ciple will apply in the case of a stricture drawn firmly
around a portion of intestine, whereby the circulation
may be suspended for many hours, without its absolute
death being effected.
If, in connection with the dark colour of the bowel,
and an apparent absence of circulation, we should find
an eflfusion of lymph and adhesions to the surrounding
parts, — the result of preceding inflammation, — the
evidence of mortification would still be insufficient, be-
cause this condition very frequently accompanies cases
of protracted strangulation in which the bowel is in a
living state.
I consider an ash-coloured and shrivelled or collapsed
state of the intestine^ as a much more certain indication
of its death, than any of the signs yet enumerated.
Several cases will be found in the different sections of
this work, which tend to prove this fact.
Another evidence of mortification has already been
ON OPENING THE SAC. 95
hinted at, and as far as my experience extends, is con-
clusive. It is the pecuhar cadaverous odour, emitted
by the contents of the sac when opened. This odour
is well understood by experienced surgeons. It is my
invariable practice, carefully to attend to it in cases of
hernia. Often have my olfactory nerves afforded deci-
sive evidence of the melancholy fact that mortification
had taken place, before my eyes have had an opportu-
nity of giving it additional confirmation.
The following highly interesting cases will confirm
the positions taken with regard to colour and the ab-
sence of circulation.
CASE XV.
Strangulated Hernia — Intestine dark, resemhling Morti-
Jication,
3c? mo. 3d, 1816. I was called in consultation at the
Almshouse by Dr. Hewson, the attending surgeon,
and met him and Dr. Dorsey at 3 o'clock. The patient
was a good-looking Irishman, of middle age, who had
long been subject to a scrotal hernia, which he was in
the habit of reducing.
The rupture had been strangulated for forty-eight
hours, during which time he had been attended out of
the house by Dr. Emlen, who had bled him very freely,
and the tobacco enema had been since administered
under Dr. Emlen's direction, without eflfect. When we
met, his pulse was upwards of 100 in the minute, and
rather feeble j tongue moist, and nearly natural in ap-
96
PROOFS OP MORTIFICATION
pearance. There was but slight tenderness or tension
of the abdomen. The scrotum was slightly oedema-
tous, and a little discoloured.
As the symptoms of strangulation were urgent, it
was concluded to operate at once. Sixty drops of
laudanum were given, and Dr. Hewson proceeded.
No difficulty was presented in the course of the ope-
ration. The sac contained a large quantity of bloody-
coloured fluid, which was not foetid. Eight or ten inches
of small intestine were found in the sac. The principal
seat of stricture was at the neck of the sac. The stric-
tured parts were divided by the blunt-pointed bistoury.
The intestine presented an unusually dark appearance,
and some portions of it were almost livid. It had a very
suspicious aspect, so much so, that doubts were raised
as to the propriety of returning it. On pressing the
part with the finger, no change was produced in its
colour; which fact indicated the absence of circulation.
My opinion as to the probable vitality of the bowel
was based upon the absence of cadaverous smell in the
contents of the sac, and upon the want of those adhe-
sions which invariably attend a mortified bowel.
As the case was doubtful, it was concluded to apply
bladders of warm water to the surface of the exposed
intestine, and return in an hour and a half, during which
time we supposed that positive evidence would be af-
forded on the point ; and we should be able to decide
whether to put it back or make an incision through the
intestine.
On our return we found a very happy change had
taken place — the dark colour had nearly disappeared —
the intestine was evidently in a state of active inflam-
mation, and during our absence a very thin, but distinct
ON OPENING THE SAC. 97
coating of coagulable lymph had covered its surface.
Under these circumstances the bowel was returned into
the abdomen. The wound was dressed with strips of
sticking plaster, and pledgets of lint, and the patient
placed in bed, with his hips elevated in the usual man-
ner ; after w hich he took an anodyne.
4th. The patient has had a good night; has passed
flatus frequently ; pulse somewhat tense. Bleeding,
with small doses of sulp. magnes., and the most rigid
antiphlogistic plan, w ere directed.
5th. Has had two free evacuations from his bowels
since yesterday, and appeared better ; pulse still tense.
We recommended the liberal use of the lancet, and
a blister to the abdomen, and the patient ultimately re-
covered, under the care of Dr. Hewson.
In this case the return of the circulation after the
removal of the stricture, proves very satisfactorily that
the dark colour was produced by the force with which
the bowel was enveloped, impeding the circulation be-
low the stricture.
The practice pursued in the above case — that of
covering the parts with a bladder filled with warm w^ater
in order to imitate the natural temperature — was derived
from my much valued preceptor. Dr. Wistar. It was
strongly recommended by him in all cases requiring
delay in the progress of the operation for hernia.
13
98 PROOFS OF MORTIFICATION
CASE XVI.
Femoral Hernia — Dark colour of Bowel — Stercoracious
Vomiting — Recovery.
8th mo. 20th, 1835. I was called this day to see the
wife of C. M., a German shoemaker in Third street, in
consultation with Dr. Moses B. Smith.
The patient is a woman of delicate form, forty-two
years of age ; the mother of five children. She states,
that nine years ago, after the birth of one of her children,
she perceived a small tumour in her right groin. It was
larger at some times than at others, but it has never
been absent. Dr. Smith had seen her on the preceding
day, and found her labouring under marked symptoms
of strangulated hernia. An old midwife in the neigh-
bourhood was in attendance before Dr. Smith. The
attack commenced with a desire to go to stool, followed
by a discharge from the bowels, accompanied with vio-
lent pain like an attack of colic. An operation had been
suggested by Dr. Smith, but was at first dechned.
When I saw her, the paroxysms of pain were ago-
nizing; the countenance was pale and dejected; the
abdomen very tumid and tympanitic ; the tongue dry
and brown ; pulse 128, irritated rather than feeble. The
operation was proposed and acceded to, and Dr. J.
Rhea Barton was called in consultation. The prospect
of success was greatly diminished just before the ope-
ration, as she vomited a quantity of clearly marked
stercoracious matter. The patient and her husband
ON OPENING THE SAC. 99
were candidly informed of the increased danger con-
nected with this circumstance, but still were desirous
that the operation should be tried. The parts were
shaved, and she was placed on a table. An anodyne ene-
ma had been previously given. Assisted by Drs. Barton,
Smith, and my son, the operation was performed about
sixty-eight hours after strangulation. A crucial incision
was made through the integuments in the usual way,
the layers of fascial were divided, and the sac exposed.
It was found to be extremely thin; great care was re-
quired in opening it ; a small portion was included in
the forceps, and the incision was made by cutting up-
wards from the contents of the sac. A small quantity
of fluid escaped, which was entirely free from cada-
verous smell ; the sac was laid fully open. A portion
of omentum, natural in appearance, first presented. On
turning aside the omentum, a knuckle of bowel was
brought into view, as dark in colour as a ripe poke-
berry, (jjJiytolacca decandra,) but it was destitute of
cadaverous smell,andthere were no adhesions from in-
flammation, such as are usually found about mortified
parts.
The stricture was divided in a direction upward and
rather inward, by the blunt bistoury ; the parts were
reduced, and the flaps of the wound approximated by
sutures.
During the operation the pulse never varied, the pa-
tient having lost very little blood ; and when it was
concluded, she declared that the pain suffered in the
operation was " nothing to compare" to that produced
by the strangulation. She was removed from the table
between 3 and 4 o'clock in the afternoon, and placed
in the usual attitude in bed. A grain of opium was
100 PROOFS OF MORTIFICATION
given her, with directions to repeat the dose in an hour
if she was restless. — Ten o'clock, P. M. The patient is
much more comfortable. She has slept occasionally,
and notwithstanding the opium, she has had four small
bilious stools. Her chief complaint is of griping pain.
Her system has reacted ; her face is flushed; skin hot ;
and her pulse 120, and febrile. Directed her to be kept
perfectly quiet ; another opium pill to be given, if she
be restless ; and a regimen of barley-water and cold
water.
21st, Morning. The patient has passed an easy night.
She took one pill of opium after the last visit. This
morning she had a return of stercoracious vomiting.
She has passed flatus, but her abdomen is extremely
tympanitic ; the urine is readily discharged ; the skin
is cooler; pulse 104; tongue red, but brown and dry
in the centre. Directed a table-spoonful of castor oil
every two hours. — Noon. She has taken one dose of
oil, and also an injection of assafoetida, after which she
had one stool. She says she "feels more natural."
Her abdomen is rather less distended; her face flushed;
skin warm, and pulse 100, and firm. — Evening. The
patient has retained three doses of oil, and rejected the
fourth, but without any stercoracious matter. No stool;
skin hot and feverish; pulse 100, and in other respects
much the same. Abdomen tympanitic ; the distended
arch of the colon, and the convolutions of intestine
being distinctly felt through the parietes. Directed
occasional injections.
22d, Morning. Has greatly improved in every re-
spect; passed a good night, and has had two large
bilious stools. Pulse 85; tongue moist; abdomen less
tumid. — Eveninor. She has had seven small bilious
ON OPENING THE SAC. 101
Stools. Still improving; pulse 80; abdomen nearly
natural. The patient relishes her gruel, and wishes it
made thicker.
23d, Morning. The patient was restless and disturbed
by dreams last night. She feels very uncomfortable, and
desires a change of posture and clothing. She has had
no stool, but passes flatus freely. Pulse 80 ; tongue
moist ; her abdomen has resumed its natural appear-
ance. Ordered a change of dress and linen. — Evening.
She has had a free discharge of indurated feces after
an enema. She takes her gruel with relish.
24th. Morning. Was somewhat feverish in the early
part of last night ; pulse SO ; no stool. I removed the
stitches from the wound. The tumour is somewhat
inflamed. — Evening. There has been one discharge
from the bowels, with scybalse.
25th. Has passed a good night. Pulse 80. The
wound is inflamed and slightly painful. Directed a
poultice to the tumour.
26th. Pulse 72. Has had one solid feculent discharge
after an enema. Tumour still inflamed. Ordered rye
mush and molasses for diet.
27th, Morning. The patient had a restless night, some
fever, and unpleasant dreams. Her bowels have not
been opened since yesterday, although an enema has
been given. The inflammation is extending around the
wound; there is burning and soreness in the part; the
appetite is diminished, and the countenance is more
dejected ; pulse 78. Directed mannaj opt. oi., sup. tart,
potassa? OSS., aqua3 bullicnta) O.ss., a Avine-glassful to be
taken every two hours. — Evening. The medicine has
operated twice. Pulse 80 ; tongue moist. Feels much
better.
102 PROOFS OP MORTIFICATION ON OPENING THE SAC.
28th. Found her in fine spirits, sitting up in bed.
She has a good appetite. The tumour is suppurating
at a small point at the inner and lower part of the
wound. The pus looks well, and is free from any un-
pleasant smell. Directed a diet of mutton or chicken
broth, rye mush and molasses, to be continued.
This patient recovered completely.
From the views now presented, I would wish strongly
to impress the young practitioner with the importance
of being on his guard in all cases of doubt. Let not
colour of the howel^ or the apparent absence of circulation
be relied on as an evidence of mortification, unless con-
nected with the collapsed state of the intestine^ and the ca-
daverous odour.
CHAPTER IV.
ON THE MANAGEMENT OF MORTIFIED BOWEL.
There are two conditions of mortified bowel which
require separate consideration. In the first, the whole
calibre of intestine is in a state of complete sphacela-
tion; while, in the second, only mortified spots are de-
tected on the strangulated part.
My experience in mortified bowel may not be as ex-
tensive as that of many practitioners. It has gone to
confirm the rule now generally adopted by surgeons,
that when the whole calibre of the intestine is actually
dead, the inflammation preceding this result has been
sufficient to fix the protuded parts to the ring and its
immediate vicinity by adhesion; and there is no reason
to fear their being drawn into the cavity of the abdomen
by the peristaltic action of the intestines: hence no
necessity exists for inflicting fresh violence on conti-
guous parts by any mode of practice designed to pre-
vent such an accident.
In cases of this description, after allowing sufficient
time to decide the question of the actual death of the
intestine, it is proper to open it by incision, and thus
allow a free discharge of fecal matter, and then to
apply simple dressings, and leave the case to nature.
Several cases of complete cure, without the occur-
rence of fistulous openings, arc related by Petit, in
104 MANAGEMENT OF
which this practice was adopted. It is remarked by
Lawrence, that almost all the numerous instances of
recovery from mortified hernia which are recorded in
the annals of surgery, took place where the surgeon
was contented to remain a quiet spectator of the pro-
cess, without interfering by any artificial attempts at
uniting the divided intestine. (Lawrence^ Amer. Edit,
p. 235.)
For the method of proceeding in these cases, I refer
especially to the case of the mulatto man at the Alms-
house, related on page 81.
The proper method of disposing of a strangulated
intestine, when mortified spots are found upon it, has
given rise to some discussion among surgeons. A prac-
tice formerly obtained, of stitching a portion of the
mesentery to the sides of the wound, to prevent the re-
turn of the diseased bowel into the abdominal cavity.
This was founded on the fear of the dead bowel being
drawn far away from the external wound by the peris-
taltic action of the intestines, and thus acting as a
foreign substance in the cavity of the peritoneum. An
additional source of danger might arise from the slough-
ing of the dead portion and the effusion of the fecal
contents of the bowels into the abdomen. But it has
since been shown, by Dessault and others, that the in-
fllammation which always precedes the occurrence of
mortified spots, is sufficient to restrain the bowel in the
immediate vicinity of the ring, and thus to insure the
passage of fecal contents through the wound.
It is therefore now generally recommended that, after
opening the sac and dividing the stricture, the parts
should be gently returned into the abdominal cavity,
MORTIFIED BOWEL. 105
leaving the result of the case to the operations of na-
ture.
My own experience as to favourable results under
any mode of treatment, is very discouraging. Hitherto
it has been my practice to return the parts as recom-
mended ; but the fatal termination of the case has so
generally followed, that I cannot speak with confidence
of any method. Cases are related, however, by Le-
dran, Petit, Dessault, Cooper, and others, which termi-
nated favourably under this method. In some instances,
without the formation of an artifical anus, and in others,
with this disgusting accompaniment.
Another plan has been proposed for the treatment of
mortified spots, which it may be proper to notice. I
allude to the applicationof ligatures with a view to hasten
the separation of the mortified parts, and to produce a
healthy union between the surfaces included in the liga-
ture. A case attended by Astley Cooper, is related by
Lawrence,* in which this practice was adopted; the
parts were returned into the abdominal cavity, and the
patient recovered. This is high authority, and should
the success of the practice be confirmed by ample ex-
perience, I should feel bound to adopt it, although its
propriety is at variance with my present opinions.
When a small portion of strangulated intestine be-
comes dead, what must be the condition of parts in its
immediate vicinity, which have not yet completely yield-
ed up their vitality ? They must certainly be in an in-
flamed condition, nearly approaching to gangrene. Un-
der such circumstances, would the application of a
ligature be most likely to result in a healthy adhesive
* Note to Lawrence on Ruptures, p. 226, Amer. Edit.
14
106 MANAGEMENT OF
inflammation of the surrounding parts, or would it
not more certainly and speedily induce mortification ?
It seems to me, moreover, that the renewal of stricture
at such a time, by a ligature, even on a small portion of
bowel, would not be in accordance with sound princi-
ples in surgery, when the whole object of the operation
is to remove strangulation as speedily as nossible. Be-
sides, it is well known that the strangulation of one side,
or slip of an intestine is sufficient to produce all the
symptoms of complete obstruction, and has sometimes
resulted in death. Several cases of this kind are related
by Hey, in his work on surgery, and one has fallen un-
der my notice at the Almshouse. Hence, would there
not be a risk of the symptoms of strangulation con-
tinuing, even after the division of the stricture, and the
return of the bowel ?
CASE xvn.
Ventro Inguinal Hernia — Mortified Spots — Testicle in-
volved in the Tumour — Death.
bth mo. 31st, 1815. I was called in haste, and after
night, to Germantown, with my friend Dr. Hartshorne,
to see J. D., a man supposed to be about forty years of
age. He had been labouring under strangulated hernia
from the preceding day, and the usual means of reduc-
tion had been used without effect by Dr. Bonsall.
Among other measures employed he had been bled;
but as there was some tension of his pulse still remain-
ing, we concluded to bleed him again, while sitting erect
MORTIFIED BOWEL. 107
in bed, until he should become fainty, and then to re-
peat the attempt to reduce the parts by taxis. After
abstracting ten or twelve ounces of blood, which did not
occasion the patient to faint entirely, the taxis was tried
in vain. We then directed an enema, gave some lauda-
num by the mouth, and after w^aiting about an hour,
proceeded to the operation.
The patient had never had a descent of the testes into
the scrotum, and there was hardly any appearance of
this receptacle. The hernial tumour was large, and of
nearly an oval form; it appeared remarkably tense,
and was painful to the touch ; but there was no tume-
faction or tenderness of the abdomen.
I made an incision through the skin and laid bare the
tendon of the external oblique muscle. On opening the
sac, the contained fluid rushed out with great force:
it had an unpleasant cadaverous smell. The first
thing that presented, was a portion of omentum, of a
dark colour, and the spermatic cord lying in front of
the sac ; for it appeared as if the omentum was con-
tained m one sac, and the intestine and the testicle in
another, which occupied the superior part of the tu-
mour. The intestine was of a dark colour, interspersed
with still darker spots, but there was no adhesion to the
adjacent parts.
The aperture from the abdomen did not appear to me
to preserve that obliquity which is peculiar to the true
abdominal canal. It seemed to be nearer to the linea
alba than is common. The stricture was firm, and must
have been very severe in its operation. After carefully
dividing the stricturing part with the blunt-pointed bis-
toury, the intestine and omentum were readily reduced.
The parts were dressed lightly, and the patient put
108 MANAGEMENT OF
to bed. The testicle was permitted to remain in the
wound, for we could not get it into the scrotum, and it
was not thought advisable to return it into the abdo-
men. After the reduction of the protruded parts, on
examining with my finger round the ring, I thought
I could distinctly perceive the pulsation of an artery
on the outer part, toward the ileum; but as I made the
incision directly upward, and with caution, it was
avoided.
The patient sustained the operation with remarkable
fortitude; but soon after he was put to bed, he was be-
dewed with a cold clammy sweat ; his pulse was 120
in the minute ; but still his respiration was good, al-
though he had occasional singultus. At first, I indulged
the hope that his symptoms resulted from transient ex-
haustion, and that his system would react ; but in this
I was mistaken. Dr. Hartshorne and myself left him at
about 2 o'clock, A. M., and at seven the same morning,
he died.
Remarks.
In this case I regret the bleeding to which we sub-
jected the patient just before the operation. Sufficient
time had been spent in eflforts at reduction, and as the
intestine was but partially mortified, it is possible that
an immediate resort to the operation might have been
successful.
It has been stated, that as a general rule, a stran-
gulated bowel in a state of mortification, will be found
so fixed by adhesive inflammation, to the immediate
vicinity of the stricture, that there exists no necessity
for applying a ligature to the mesentery to prevent
its retrocession. Cases, however, may occur, that
MORTIFIED BOWEL. 109
may be regarded as exceptions to the general rule ; or
rather, that at the time of the operation, may lay out of
the rule, and may subsequently be attended with diffi-
culty and danger. I believe that the injury infficted on
an intestine by the severe strangulation or pinching of
so delicate a part, may prove sufficient ultimately to
deprive it of vitality, even after the original cause is
removed. All this may occur. The intestine, at the
time of the operation, may not present any of the ap-
preciable evidences of gangrene which would call for
specific treatment. It may be returned within the cavity
of the abdomen: — it may recede to some distance from
the ring — and, days afterwards, the fairest prospects of
a recovery may be blasted by the separation of a small
slough from the side of the bowel. The contents of the
intestine may pass into the cavity of the peritoneum,
and may actually be diffiised extensively between the
folds of the intestines.
The following case aflfords a striking illustration of
this fact.
CASE XVIII.
1st mo. 24th, 1831. I operated to-day, at about one
o'clock, P. M., for strangulated femoral hernia, on M.C.,
the wife of a respectable merchant, and the mother of
twelve children, several of whom are yet young. She
had been subject to a femoral hernia in her right groin
for about a year, and by my advice, had worn a truss.
The strangulation occurred in the act of vomiting, when
the truss was off.
110 MANAGEMENT OF
I was called to visit her with my friend Dr. Janney,
within twenty-four hours after the strangulation. There
were some interesting particulars in the case. I was
informed, that in the commencement of the attack the
pain in the abdomen was very violent, and the vomit-
ing severe ; but that these symptoms had subsided
without any treatment to explain it. She had a large
feculent discharge, which appeared to contain recent bile,
and which occurred without any artificial means, some
hours after the operation of an injection of decoction
of senna.
Although 1 was accustomed to see discharges directly
after strangulation, yet in this case, I confess I was in-
duced to believe that the stricture was removed; par-
ticularly as the violent symptoms which marked the
attack in its commencment had greatly moderated.
On the following day, I discovered that the symp-
toms had increased, though they were not urgent. The
patient had no pain on pressing on the abdomen, or on
the tumour in the groin ; though the symptoms were
sufficiently marked to induce the suspicion of stran-
gulation.
On the day preceding the operation, she had re-
peated efforts at stool, with occasional slight discharges
of feculent matter, and copious discharges of flatus.
The symptoms, however, though not violent, continued
unabated. She had no pain, but an increasing languor,
and indescribable distress, nausea, and occasional vo-
miting; distressed countenance; eructations and tym-
panitic abdomen; all of which proved the existence of
strangulation.
Dr. J. Rhea Barton was associated with us in con-
sultation; the usual remedies for reduction were faith-
MORTIFIED BOWEL. Ill
fully triedj and the operation was proposed on several
occasions; but the patient strongly objected, and did
not consent until the 24th — being the fourth day from
the commencement of the strangulation.
I performed the operation, assisted by Drs. Barton
and Janney, and my son. No unusual appearances were
presented. The sac contained a small quantity of fluid,
and a knuckle of bowel in an inflamed condition, but not
gangrenous. No cadaverous odour could be detected.
The stricture was divided and the parts returned.
24th. Evening. The patient had two evacuations;
after which, an injection of lac. assafcetida was admin-
istered, and produced copious discharges of flatus,
and the bowels were freely opened, to her great relief.
Her stomach is retentive; the eructations have nearly
ceased; and the tympanitis is much diminished. Her
pulse is intermittent, and beats 80 times in the minute.
A hop pillow was used during the night.
25th. Morning. The patient slept four hours during
the night. An enema of assafoetida was administered
about midnight. She had two small discharges from
the bowels, and passed flatus. Pulse about 100. The
patient is perfectly free from pain; her abdomen soft;
her stomach retentive; and she is entirely relieved from
nausea and eructations. Her mouth and tongue are
dry; but the thirst, which was excessive during the
strangulation, is now much diminished. Directed a
liquid farinaceous diet, and a repetition of the injection
of assafoetida, if the bowels should be uneasy. — Even-
ings 6 o'clock. She has passed a comfortable day. The
mouth and tongue are less dry; thirst diminished. The
abdomen is not painful on pressure, though still slightly
tympanitic. Pulse 100. Directed an injection of assa-
112 MANAGEMENT OF
foetida. — 10 o'clock. After taking a wine-glassful of thin
gruel, sweetened with sugar, she complained of most
violent pain in the belly, and in a moment she became
extremely ill and very much agitated. Dr. Janney and
myself were speedily called. We found her pulse tense
and full, beating 80 strokes per minute. She was freely
bled, about twenty ounces being taken, which her pulse
bore well; and we directed an injection of assafoetida
with sweet oil and water. Dr. Janney remained with
her.
26th. Mornings h past 9. The patient has passed a
wretched night. There has been no passage from the
bowels, although she has taken four table-spoonfuls of
castor oil. She has had a return of the eructations, but
no vomiting. The abdomen is very tender to the touch,
and somewhat tympanitic. The countenance dejected.
Pulse 120, and rather weak. The blood drawn last
night has no size upon it. Dr. Janney remained with
the patient until 2 o'clock, P. M. He applied a spice-
plaster over the stomach, and gave her an anodyne
enema; but all in vain. The patient died.
Dissection. — Dr. Janney and my son examined the
body, and afterwards informed me that there was
found a perforation of an oval form, on one side of the
small intestine, evidently formed by the rupture of a
slough. Through this opening the contents of the
bowels, to the amount of at least a pint of fluid foeces
had been evacuated, and diffused amongst the convolu-
tions of the intestines. The parts around the slough
were but little altered from their natural appearance,
and the size and shape of the mortified portion induced
the belief that this portion had been grasped by the
stricture. The intestines occupied their natural posi-
MORTIFIED BOWEL. 113
tion; there were no adhesions of the mortified portion
to the peritoneum, and the bowel had receded about
two inches from the ring. General peritoneal inflam-
mation had been caused by the effusion of feces, and
slight adhesions between the convolutions of the intes-
tines had taken place.
15
CHAPTER V.
ARTIFICIAL ANUS.
When a strangulated bowel becomes mortified, if
death does not ensue, the skin over the tumour sloughs,
and the feces are discharged through the opening, form-
ing an artificial anus.
This is certainly one of the most loathsome condi-
tions to which a human being can be subjected. It is
really deplorable for a person of decent habits to pos-
sess no power over the alvine discharges.
The artificial anus may be divided into two species.
The mildest and most manageable form is generally
slow and insidious in its approach. From the course
of the symptoms we are led to the conclusion, that a
small portion of the calibre of the intestine becomes par-
tially strangulated. The parts around inflame, and are
agglutinated to each other— suppuration takes place,
and an opening is formed by the ulcerative process, be-
tween the bowel, the sac, and the integuments — and
an abscess appears externally.
All this may be accomplished with very little consti-
tutional disturbance, and the first eyidence of a con-
nection between the abscess and the intestine, will be
exhibited by a discharge of feces and flatus at the
groin.
ARTIFICIAL ANUS. 115
Patients of this description may recover completely
under the cm'ative efforts of nature. 1 have seen several
instances of this disease, which I will briefly narrate.
CASE XIX.
fith mo, 3d, 1828. I was accustomed to attend a re-
spectable old lady of this city, of delicate constitution,
and subject to chronic cough. While I was in attend-
ance, on a late occasion, she called my attention to a
small tumour in the groin, which excited no particular
anxiety in my mind; and I contented myself with direct-
ing emollient applications, supposing it might be a sim-
ple abscess. It advanced very gradually to suppuration:
when this occurred, it was discovered that flatus, and
thin feculent matter were discharged through the open-
ing. At the same time the natural discharges through
the rectum were not materially interrupted.
The patient was very far advanced in years, and died
in about three months, from a gradual failure of the
powers of nature. The discharge did not appear to
have any agency in the event — during the last month
of her life it had nearly ceased — and appeared to be
gradually diminishing.
During the whole time the functions of the stomach
and bowels were not strikingly impaired.
116 ARTIFICIAL ANUS.
CASE XX.
10th mo. 25th, 1824. I accompanied the late Dr.
Perkin to see S. S., a young female upon whom he was
attending. She had been subject to a small tumour in her
right groin from childhood. About four weeks previous
to my visit, while in the act of vomiting, she had an in-
crease of the tumour, and an attack of colic. By the
aid of injections, and a dose of castor oil, she was re-
lieved, and the next day was pursuing her usual avoca-
tions. Four days after this she partook of cold-slaugh,
(i.e. chipped cabbage,) and was again attacked with the
symptoms of colic, from which she was relieved by the
same means.
At this time she called Dr. Perkin's attention to the
tumour in her groin — it was about the size of a bubo,
and inflamed. A poultice was directed, and in a few
days suppuration took place, and feculent matter was
discharged through the abscess. Four days after this,
she had a discharge from the rectum, and w^as greatly
relieved.
She was kept upon a soft diet, and finally recovered.
This case is compiled from rough notes taken at the
time, and is not as detailed as I should wish. Dr. Per-
kin is deceased, and I am not in possession of a more
complete history.
ARTIFICIAL ANUS. 117
CASE XXI.
Umhilical Hernia — SloitgJiingExternally — Natural Cure.
In the autumn of 1827, I was called in consultation
with Drs. Ellis and Lukens, to visit the wife of J. L., a
worthy old citizen residing in Front street. The patient
was a large, corpulent woman about seventy-seven
years of age. She had lately received a strain by falling
out of bed; and a few hours afterward, a small tumour,
about the size of a walnut, w as discovered at the um-
bilicus.
She had been for many years subject to colic, and
was seized, a few days previous to my visit, with an un-
usually severe attack, which had not yielded to the
usual remedies. Dr. Lukens, the family physician, was
called, and found the bowels obstinately constipated,
with considerable pain in the abdomen. He prescribed
the ordinary remedies without the desired effect. Dr.
L. being absent from the city, Dr. Ellis saw her. The
symptoms continued for several days, when the atten-
tion of her daughter was drawn to the tumour at the
umbilicus — it was discharging a greenish offensive mat-
ter. Dr. Lukens was sent for, and at once discovered
the true character of the case, and I was requested to
see her in consultation. At this time she was dischars-
ing large quantities of feculent matter from the open-
ing, and the evacuations from the anus were suspended
for several days. She suffered much from excoriations
over the abdomen caused by the contact of feces. We
attempted to close the opening by compresses and
118 ARTIFICIAL ANUS.
bandaging, but this evidently increased the distress of
the patient. The sore was therefore left open, and large
quantities of mucilage of gum Arabic were applied
over the abdomen, to shield it from the irritating effects
of the discharges. The discharge continued for several
weeks, and finally ceased entirely; the sore healed, and
the patient completely recovered. While the discharge
was declining, the patient took a dose of sulp. magnes. to
open the bowels; during the operation of the medicine
the sore was re-opened, and the discharge was renewed
as copiously as at first. After this, the bowels were
moved by enemata, and the patient was confined to a
farinacious diet during the whole course of the attack.
Remarh,
It will be observed, in the above case, that a purga-
tive caused serious mischief in the progress of the cure.
The great principle of treatment in these cases seems
to be, to avoid all kinds of cathartics, and to confine
the patient to a mild, soft diet. Among other articles,
rye mush and molasses are well adapted to such cases.
The danger attending an artificial anus, depends
upon the part of the intestine which has been involved
in the stricture and becomes mortified.
If a portion of the jejunum be opened, the chyle
which was intended for the nourishment of the system
may pass out externally: a patient in this condition
becomes enfeebled and emaciated, and dies. A case
of this description fell under my observation at the
Pennsylvania Hospital. It is next narrated, as reported
in my hospital-book by my friend and former pupil Dr.
Caspar Morris, who was then house-surgeon.
ARTIFICIAL ANUS. 119
CASE XXII.
Artificial Anus — Exhaustion — Death.
Isaac Lewis was admitted a patient into the Penn-
sylvania Hospital at some time during the sixth month,
1824. He had been afflicted with congenital scrotal
hernia, on the right side, until some time in the preced-
ing summer, when he was attacked by what was sup-
posed to be colic, by his physician in the country, and
he was treated accordingly. Sloughing of the integu-
ments about the scrotum took place, and one of the
testicles became involved in the disease. Such was the
only account we could obtain from the patient.
On his admission, a sinous opening was discovered
near the external ring. From this orifice there was a
discharge, the nature of which led to some discussion
among the surgeons of the institution, some of whom
judged it to be chyle, and others thought it was merely
purulent matter. Considerable quantities of flatus also
escaped, particularly when the patient rose, or when
pressure was made on the abdomen. The man was in
an extremely weak and emaciated condition, and had
an obstinate diarrhoea, together with hectic fever. His
appetite was enormous, and by the use of tonics and
very nourishing diet, his health improved, though he
continued too feeble to sit up or walk.
About the 15th of the Tenth month, Dr. Barton, assisted
by Drs. Hewson and Parrish, made an incision through
the integuments, and traced up the sinus to the internal
ring. He was able to pass a probe for some distance
120 ARTIFICIAL ANUS.
further, but whether into the abdomen or into a sinus
between the muscles and the peritoneum, could not be
determined. After the operation he was put to bed,
and very soon discharged both from the wound and the
rectum, a matter very closely resembling the shreddy
evacuations often noticed in chronic dysentery. The
connection between the sinus and the intestinal canal
was thus demonstrated beyond the possibility of doubt.
From this time until the death of the patient, which
occurred about ten days after, he continued to have fecal
discharges from the wound.
Dissection. On examination, the following appear-
ances were presented in the abdomen. The whole of the
small intestines were found agglutinated by adhesions
to each other, to the omentum, and to the abdominal
parietes. On the right side the adhesion connected a
portion of the jejunum to the peritoneum just within
the opening of the sinus, and a probe might be passed
for a considerable distance into the belly, along a sinus
formed between two barrels of intestine, following the
course of the colon. Towards the left side, nearly oppo-
site the opening on the right, was found the cause of
the mischief: about three inches of the intestine was
united by adhesion to the peritoneum lining the trans-
verse muscle, and at this point there was a communica-
cation between the cavity of the bowel and the sinus
already described.
The attempt was made to explain these appearances
in the following manner. It is probable, that after the
strangulation and during the consequent sloughing of
the bowel, it receded from the mouth of the sac, and
took its position on the left side of the abdomen, adher-
ARTIFICIAL ANUS. 121
ing to the surrounding parts in such a manner as nearly
to restore the regular route of the alimentary canal; but
that, in the mean time, feces had escaped into the cavity
of the peritoneum, producing universal peritonitis. It
is evident that the feces thus effused, had been shut in by
adhesions, and that, in travelling toward the right abdo-
minal ring, which offered the only outlet, they had
established the fistulous sinus which caused the death
of the patient.
When the whole calibre of the intestine included in
the stricture becomes mortified, a deformity of the most
disgusting character is the result. The bowel being
doubled upon itself, two openings are formed, through
the upper of which, feces and flatus escape. The sides
of the intestine are agglutinated to each other by ad-
hesive inflammation for some distance, presenting an
appearance which has been aptly compared to a double
barrelled gun.
A case of this kind fell under the care of Drs. Wis-
tar and Physick at the Pennsylvania Hospital, in 1809,
in which Dr. Physick conceived and executed a most
admirable plan for the relief of the patient. A full ac-
count of this interesting case was drawn up by Dr. B.
H. Coates, and published in the N. Amer, Med. and
Surg. Journ. vol. ii. p. 269. That part of the history
which relates to the operation I have extracted.
" The next method proposed by Dr. Physick, was to
cut a lateral opening through the sides of the intestines
where they were adherent. But not knowing the extent
of the adhesion inwards, he thought it necessary to
adopt some preliminary measure for insuring its exist-
ence to such a depth AS might admit of the contem-
plated lateral opening without penetrating the cavity of
16
122 ARTIFICIAL ANUS.
the peritoneum. By introducing his finger into the in-
testine through one orifice, and his thumb through the
other, he was enabled to satisfy himself that nothing
intervened between them but the sides of the bowel.
He was thus enabled without risk to pass a needle,
armed with a ligature, from one portion of the intestine
into the other, through the sides which were in contact,
about an inch within the orifices, which ligature was
then secured with a slip knot.
" This operation was performed on the 28th of Ja-
nuary, 1809. The ligature was merely drawn sufficiently
tight to insure the contact of those parts of the perito-
neal tunic which were within the noose. When drawn
tighter, it produced so much pain in the upper part of
the abdomen, of a kind resembling colic, that it became
necessary immediately to loosen it. The ligature, in this
situation, gradually made its way by ulceration through
the parts which it embraced, and thus loosened itself.
It was, at several periods, again drawn to its original
tightness.
" After about three weeks had elapsed, concluding
that the required union between the two folds of peri-
toneum was insured. Dr. Physick divided with a bis-
toury all the parts which now remained included within
the noose of the ligature. No unfavourable symptom
occurred in consequence.
" On the 28th of February, the patient complained
of an uneasy sensation in the lower part of the abdo-
men; and, on the 1st of March, he extracted with his
own fingers some portions of hardened feces from his
rectum. On the 2d of March, two or three evacuations
were produced in this manner. On the 3d, an enema,
consisting of a solution of common salt was directed to
ARTIFICIAL ANUS. 123
be given twice every day. The first of these occasioned
a natural stool, about two hours after its administra-
tion. The same effect was produced on the 4th, 5th,
and 6th; and the discharges from the orifice in the
groin now became inconsiderable. Adhesive plasters,
aided by compresses, were employed, not only to pre-
vent the discharge of feces from the artificial opening,
but with the additional object of procuring the adhe-
sion of its sides. This last efibrt was unsuccessful.
" On the 24th of June, an attempt was made to unite
them by the twisted suture. Pins were left in for three
days, and adhesion was, in fact, eflfected; but owing to
the induration of the adjacent parts, the wound again
opened."
The hope of an entire closure of the orifice was
finally abandoned. But the discharge of feces was effec-
tually prevented by the application of a truss, with a
compress and large pad.
On the 10th of November the patient was discharged
from the hospital in good health and spirits, and applied
himself, with very good success, to acquire the profes-
sion of an engraver.
Had health been restored in the patient, whose case
is detailed at page 81, (case xii.) I should have at-
tempted to cure the artificial anus by Dr. Physick's
method.
CHAPTER VI.
ENTERO-EPIPLOCELE.
It not unfrequently happens that omentum and bowel
are both contained in a hernial sac; and when strangula-
tion occurs under these circumstances, the case is ren-
dered more complex and difficult.
The omentum, in some instances, assumes such a
form as to contain within it a cavity, into which the
bowel descends and becomes strangulated. If this pe-
culiar relation of the parts is not well understood by
the surgeon, he may be greatly embarrassed in the ope-
ration, at a moment when he should proceed with calm-
ness and confidence.
In the preceding cases we have considered only one
hernial sac, as the investment of strangulated parts —
we have noticed the difficulties of opening the sac, from
an absence of fluid and other causes, but still when the
opening is eflfected, the whole contents have been fairly
exposed. But what must be the feelings of a young
surgeon, perhaps in his first operation, when he has
succeeded in detaching a hernial sac from its adhe-
sions, and brings into view a mass of omentum, firmly
impacted together by strong adhesive bands? What is
now to be done? the sac is opened, but no strangulated
bowel can be discovered, although the symptoms une-
quivocally proclaim its existence. To suspend all fur-
ENTERO-EPIPLOCELE. 125
thcr proceedings, dress the wound, and place the patient
in bed, is to consign him to death, after having sub-
jected him to the most painful part of the operation.
The object must be steadily pursued, the operator must
recollect that a cavity is to be found in the centre of the
omental mass, which contains the strangulated bowel :
he must divide the omentum, cutting as it were through
the crown of an arch, and he will then discover that
there is a sac within a sac, and the intestine will be
brought into view.
The proper disposition of the omentum in an entero-
epiplocele demands the careful consideration of the sur-
geon. This part may be found very much altered from
its original structure, from the fact of its having been
long excluded from the abdomen; it may be in a state
of mortification, from the effects of severe strangula-
tion; or it may have recently descended, and be in a
state of acute inflammation.
The first of these conditions I shall designate by the
term
EXPATRIATED OMENTUM.
Some readers may smile at this term; but perhaps
they may be convinced that it conveys a brief but just
illustration of the condition of the parts.
It is possible for a man to absent himself for so long
a period from his native country, that his early associ-
ations may be completely dissevered. He may acquire
new views, he may cultivate other affections, and may
become estranged from the land which gave him birth.
In the course of events, such an ahen from his country
may return as an enemy, clothed in hostile array.
126 ENTEIIO-EPIPLOCELE.
So it is with the omentum; a portion of this structure
may be separated for so many years, from the cavity
of the abdomen, that it may entirely lose its native cha-
racter. Instead of a soft, yielding apron of fat, destined
to spread over the delicate bowels, it may become con-
verted into a solid mass, bearing no resemblance to its
original structure, and totally unfitted for the perform-
ance of its appropriate functions. It is expatriated, and
has become an alien from its native home.
If in this condition it be forcibly returned within the
cavity from which it originally escaped, it may act as
an extraneous body, and may prove an agent of dis-
cord, danger, and death.
The treatment of omentum in this condition demands
serious consideration, and not unfrequently surgeons of
acknowledged eminence have been led into difficulties.
The following case, extracted from Hey's Surgery,
affords a striking evidence of the danger of returning a
diseased mass:
" February 1st, 1789. I was called in the afternoon
to visit Robert Walker, a poor man, aged thirty-seven,
who was in great pain from a strangulated hernia. He
had been subject to the hernia for many years. It had
several times been strangulated for a few hours, accord-
ing to his account, and could never be entirely replaced
within the abdomen. The strangulation at this time
had commenced the preceding evening at 8 o'clock,
soon after which he had a stool, but afterwards had no
evacuation. He vomited sometimes, and had a little
hiccough. His belly was somewhat tense, but not much
inflated. His tongue rather white. His pulse soft and
calm at sixty-four. The lower part of the tumour in
the scrotum was soft; the upper part was hard. The
ENTERO-EPIFLOCELE. 127
scrotum was so thin, that I could feel the omentum
within the hernial sac.
" I ordered a clyster, made with two drachms of to-
bacco boiled in a pint of water for ten minutes, to be
injected; and cloths dipped in cold water to be assidu-
ously applied. I did not bleed him, as his pulse was so
soft and calm. The clyster had a powerful effect, pro-
ducing great sickness and vomiting, with a cold sweat,
during which the pulse sunk to fifty-six. I attempted
during this languor to reduce the hernia, but in vain;
not the least motion was produced by my attempts.
" I most strongly recommended the operation, and
advised the poor man to go into the infirmary, as the
accommodations of his house were very bad. My ad-
vice did not prevail, so I gave him in the evening fifty
drops of tinct. opii., which entirely removed his pain
and vomiting. The next day the poor man consented
to go into the infirmary, but not till towards evening.
The pain had now returned, the abdomen was more
inflated and tense, and the tumour was larger. The
operation was immediately performed.
" Not the least quantity of fluid issued out when the
hernial sac was opened. A large portion of omentum,
and a smaller of intestine, were the contents. The former
appeared to have laid a considerable time in the her-
nial sac; for it not only adhered to the sac in many
places, but also had formed in it several small pouches,
in which it lay depressed beyond the level of the sac.
The intestine was dark-coloured, but had contracted no
adhesion. The stricture was not formed by the abdo-
minal ring, but entirely by the neck of the hernial sac,
into which I could not introduce the least portion of
my finger.
128 ENTERO-EPIPLOCELE.
" I was obliged to divide the ring pretty high, that I
might with safety divide the neck of the sac; and this
last division was effected by cutting along the groove
of a director, till I had made a sufficient aperture for
the introduction of my finger. As the omentum adhered
to the sac by little cords, which might easily be divided,
I separated it from the sac, and reduced it immediately
after the intestine. This was easily reduced, but the
reduction of the omentum gave some trouble. The
omentum did not feel brittle, nor appear to be in a gan-
grenous state. When the contents of the hernia were
reduced, some serous fluid issued out of the abdomen.
A purging clyster was ordered to be injected; and- he
was directed to take half an ounce of castor oil every
two hours, till a free evacuation should be produced.
" February 3d. I found him in a good state at noon;
the clysters had produced a stool, and after the second
dose of castor oil he had three evacuations. His pulse
was at eighty-six.
" Notwithstanding these favourable appearances, the
symptoms of inflammation, such as vomiting, soreness
of the abdomen, with considerable pain, returned in the
evening. Eight ounces of blood were taken from his
arm; a clyster was injected; the ol. ricini was repeated;
and a large blister was applied to the abdomen. These
means afforded no relief, and the poor man died at
seven in the morning.
" In the evening I examined the contents of the abdo-
men. The intestines appeared in many places inflamed,
and adhered to each other universally. That part which
had been strangulated was of a darker colour. The
omentum did not cover the anterior surface of the in-
testines as usual, but passed down on the left side of
ENTERO-EPIPLOCELE. 120
the abdomen, collected together like a thick rope. The
strangulated portion had now become very brittle, and
was dark coloured at its inferior part. Bloody serum
was contained within the abdomen."
Here is an instance of death resultincr from the
practice of returning a portion of expatriated omentum
into the abdominal cavity. A case somewhat similar,
though not resulting in death, occurred several years
ago in the Pennsylvania Hospital, under the care of Dr.
J. Rhea Barton.
A patient was admitted with strangulated entero-
epiplocele, and was operated upon by Dr. Barton. A
large mass of hardened omentum was found in the sac,
which was returned with the bowel into the abdomen.
A train of the most alarming symptoms speedily en-
sued, causing great solicitude for the life of the patient.
Finally, abscess formed in the groin, at the wound,
through which several large masses of dead omentum
were discharged. Dr. Barton thought that the quantity
of solid matter discharged, was almost equal to three-
fourths of the whole omentum in its natural state. The
discharge was kept up for several weeks, during which
time the strength of the patient was supported by a
generous diet, and he was ultimately discharged cured.
A practice was reconmiended by some of the old
writers, which is still more dangerous than the preced-
ing. It consisted in tying a ligature firmly around the
root of the hardened mass, removing the portion below
the ligature, and returning the part with the ligature
attached, and its end retained on the outside. A num-
ber of cases are on record, where this practice has
actually proved fatal, even in the hands of eminent
surgeons.
17
130 ENTERO-EPIPLOCELE.
In the surgical works of Percival Pott, a case is
very candidly stated, in which this practice caused the
death of an individual.
The patient had long been affected with a bubono-
cele, which was inconvenient from its bulk alone — he
applied to Pott to remove it, which he accordingly did.
A ligature was applied around the root of the diseased
mass, and the omentum below removed. The patient
at the time of the operation was in perfect health; but
a train of the most violent symptoms ensued, which
resulted in his death.
So many proofs of the dangerous effects of this plan
of treatment have been adduced, that I believe it is now
generally abandoned.
To counteract the dangers arising from this plan, it
was recommended by Pott to excise the diseased
omentum, and return the sound parts into the abdomen
without the application of a ligature at its root. He
believed that the risks of hemorrhage by such a course,
were much less than surgeons generally supposed.
I have never seen this practice adopted, and there-
fore cannot speak of it from experience; but I should
consider that the division of the large blood-vessels,
near the root of the omentum, must necessarily give
rise to bleeding, which would prove dangerous to the
patient. At the same time it must be admitted, on the
authority of Pott, that the practice has in some cases
been safely pursued. Two cases are reported by Hey,
of Leeds, in which he pursued this practice, on the re-
commendation of Pott, and dangerous hemorrhage
ensued. An abstract of one of these I shall detail in
this place, in the absence of any experience of my own.
It is taken from Hey's Surgery, p. 188, second edition.
ENTERO-EPIPLOCELE. 131
" Case. — The hernial sac contained a good deal of
serous fluid, besides a pretty large portion of intestine
enveloped and completely covered by omentum. The
neck of the hernial sac, below the abdominal ring,
formed so considerable a stricture, that I could not in-
troduce the tip of my finger to guide the curved bis-
toury. It even required some force to introduce a di-
rector suitable to this occasion. After dividing the neck
of the hernial sac, I could easily introduce my finger
within the abdominal ring, which I also divided suffi-
ciently to permit the reduction of the intestine.
" The omentum was become gangrenous; and in one
part adhered pretty strongly to the intestine. That
part of the intestine which had been enclosed in the
stricture made by the neck of the hernial sac, appeared
as if it had been tied round by a string. The colour
was so much altered by this impression, that we were
under considerable apprehension of a separation taking
place at this part. I endeavoured to reduce the intes-
tine with all possible gentleness, after I had separated
it from the omentum; yet, notwithstanding all the cau-
tion I could use, I was much afraid that the operation
would not preserve the life of my patient, even if no
injury should arise from the morbid state of the omen-
tum.
" I had always been afraid of large wounds of the
omentum; but as the excision of a gangrened portion,
by cutting through the adjacent sound part, stood so
strongly recommended by Mr. Pott, of whose judgment
I had a very high opinion, I determined to follow his
example in this instance. I cut off", therefore, all that had
a morbid appearance; and the remainder, as soon as I
132 ENTERO-EPIPLOCELR.
had ceased to hold it, retired spontaneously into the
abdomen.
" A hemorrhage immediately ensued, which from the
distinct colours of different parts of the stream, evidently
consisted both of arterial and venous blood. The dis-
charge of blood diminished so much in a short time,
that I ventured to unite the divided integuments through
the whole extent of the wound, by the interrupted suture.
I ordered a purging clyster to be injected, and half an
ounce of ol. ricini to be given every three hours, till a
free evacuation should be produced.
" I visited the patient about two hours after the ope-
ration and found him asleep.
"At ten in the evening I was called to him, on account
of a violent hemorrhage, which the nurse had just dis-
covered. The blood had flowed through his bed upon
the floor. I immediately cut out the ligatures which
were in the upper part of the wound, both to give a free
issue to the blood, and also to enable me to know the
true state of the hemorrhage. The blood which now
issued out appeared to be venous. It flowed irregularly,
sometimes ceasing for ten or twelve minutes. I applied
cloths dipped in cold water to the abdomen and scro-
tum, and kept dabbing the wound with a cold wet
spunge. His pulse was weak, and at a hundred and
eight. His countenance more pale; the belly less tense;
he had one stool. I left him at half past eleven, as the
hemorrhage had then abated, desiring the house apo-
.thecary and my senior pupil who remained with him,
to continue the application of the cold cloths till the
hemorrhage should cease, and to give the ol. ricini
every three hours.
ENTERO-EPIPLOCELE. 133
" 27th. The hemorrhage ceased at half past one in the
morning."
The patient finally recovered; and the experienced
writer makes the following remarks:
" This case clearly shows, that large wounds of the
omentum are attended with danger, if the bleeding ves-
sels are not tied. As the termination was favourable, I
am not sorry that the operation was performed, as Mr.
Pott and Monsieur Caque have advised; but I shall
never again cut off any large portion of omentum, with-
out applying a ligature to every bleeding vessel, whe-
ther artery or vein, before I permit the remainder of
the omentum to retire into the abdomen."
A third plan of treatment consists in the excision of
the diseased mass, securing the divided blood-vessels
separately, by fine ligatures, and returning the parts,
allowing the ends of the ligatures to remain outside of
the w^ound.
This practice is, I believe, very generally recom-
mended by surgical writers at the present day; but I
must confess it is utterly at variance with my views of
sound surgical principles. By such a course the imper-
fection of one of the most important cavities in the
body is maintained for many days, and the patient is
also subjected to the additional risk of peritoneal in-
flammation, arising from the presence of extraneous
bodies.
In pursuing such a plan, do we not carry out the same
principles which govern us in the operation for the ra-
dical cure of hydrocele? If the introduction of a seton
or ligature in the cavity of the tunica vaginahs testes
will cause acute inflammation, the effusion of lymph,
and adhesion between the opposing surfaces of the
134 ENTERO-EPIPLOCELE.
peritoneum, the same result may be anticipated in an-
other cavity hned by the same membrane.
If the ntihty of this practice were confirmed by am-
ple experience, I should be disposed to adopt it, although
in opposition to my present views. I have searched in
vain for its confirmation, by detailed accounts of cases
in which such a course has been sucessfully pursued.
A case is published by Everard Home, in the Trans-
actions of a Society for the Improvement of Medical
and Chirurgical Knowledge, vol. ii. p. 99, in which he
pursued this practice; and its result is certainly not cal-
culated to make a very strong impression in its fa-
vour. The patient was afflicted with strangulated fe-
moral hernia; and the writer, after describing her sym-
toms, &c. thus proceeds :
" When I laid open the hernial sac in the usual man-
ner, nothing except omentum was brought to view; but
when this was spread out, and turned up towards the
abdomen, a small tumour, formed by the doubling of
the intestine, was discovered at the bottom of the sac,
which was so much pressed upon by Poupart's ligament,
as not to admit the end of a probe to pass between
them. The gut was very much inflamed, its surface
was perfectly smooth, and uniformly of a dark red co-
lour; but as mortification had not taken place, it was
thought to be capable of recovery, and was, therefore,
as soon as the ligament was divided, returned into the
belly. The portion of omentum adhered to the orifice
of the hernial sac, and was found upon trial too large to
pass through the orifice which led to the abdomen; it
was, therefore, from necessity, removed; this was done
by dividing it in its expanded state, near the orifice of
the sac, with a pair of scissors; two arteries on the cut
E^fTERO-EPIPLOCELE. 135
edge bled so violently as to require being secured by
ligatures, the ends of which were brought out at the
external wound and the whole was superficially dressed.
" As the portion of gut was very much inflamed,
twenty drops of tincture of opium were given imme-
diately, to lessen the irritation produced by the inflam-
mation, and repeated at four in the morning.
" January 2d. The retching was entirely stopped,
and the pain in the belly much abated. A glyster of
warm water was injected, and fifteen drops of tincture
of opium given in a draught, both of which were re-
peated at night. The glysters were only retained about
an hour.
" January 3d. She was totally easy, but languid; the
glyster of warm water was repeated: at ten in the even-
ing she had a pain in the lower belly, for which she
took twenty drops of tincture of opium: the same quan-
tity of opium, in consequence of a continuance of the
pain, was repeated at one in the morning.
" January 4th. The pain continued with a constant
desire to make water; the belly was fomented, after
which she made water freely, and this relieved the pain
in the belly. At 2 o'clock she took an ounce of a mix-
ture containing svj. of infusion of senna, 3vj. of tinc-
ture of senna, and 3iii. of kali tartarisatum, and in an
hour had a motion; her pulse was soft, and beat a hun-
dred times in a minute; her thirst continued, but was
relieved by sucking oranges. She took some panada,
sago, and her usual opiate at night.
" January 5th. Had a confusion in the head, with
disturbed dreams; these were considered as effects of
opium, which was therefore left off*. The wound had a
favourable appearance.
136 ENTERO-EPIPLOCELE.
" January 7th. The hgatures came away, and the
wound was going on kindly,
" January 9th. She became restless, feverish, lan-
guid, and had no appetite for food; all these symptoms
increased on the 10th, and on the 11th at night, she
died, exactly ten days after the operation.
" On inspecting the body after death, the strangulated
portion of intestine, extending to two inches and a half
of the ileum in length, was found to have exactly the
same appearance as it had when exposed during the ope-
ration. Its internal membrane was extremely vascular,
and had an inflammatory exudation of coagulating
lymph adhering to different parts of its surface. There
was no appearance of inflammation on the omentum.
So large a portion of it had been removed during the
operation, that only an inch of its anterior part re-
mained attached to the transverse arch of the colon.
In several parts of the abdomen there were slight adhe-
sions between diflferent convolutions of the intestines."
In this case the symptoms were, from the beginning
of the attack, those of an inflamed intestine; the ope-
ration arrested the progress of the inflammation, and
prevented mortification from taking place; but the in-
flammation had proceeded too far to admit of resolu-
tion.
The death of the patient is referred to enteritis, in-
duced previously to the operation. But whether the
hgatures, by acting as extraneous bodies in the abdo-
minal cavity may not have an agency in increasing the
inflammation, and producing those adhesions between
diflferent convolutions of the intestines, is undeter-
mined.
In the valuable work of Astley Cooper on the Ana-
ENTERO-EPIPLOCELE. 137
tomy and Surgical Treatment of Inguinal and Congeni-
tal Hernia, I find the following remarks in reference
to the treatment of diseased masses of omentum.
" When the intestine has been returned, the omen-
tum is to be examined with attention, and if it is in a
healthy state, or not of considerable bulk, it should be
returned into the cavity of the abdomen by as slight a
pressure as possible. But if it is very bulky, a part of it
should be removed, which may be done with the knife
with great freedom, and if properly managed, without
any danger. I have myself removed it, in several in-
stances, without the patient seeming to suffer any sub-
sequent inconvenience.
" The surgeon raising the omentum, whilst an assist-
ant grasps it higher up, to prevent its return into the
abdomen, cuts it off near the mouth of the sac. Some
small arteries always bleed, which are to be secured
by a fine ligature; and when the hemorrhage is stopped,
the omentum is to be returned into the abdomen, with
its divided surface applied to the , mouth of the sac,
from which the ligatures are suspended, and it thus
forms a plug which shuts up its cavity." P. 32.
The recommendation of a surgeon so justly distin-
guished as the writer of the above quotation, is entitled
to high respect, and it is with diffidence that I offer a
few plain objections to the practice here proposed.
The omentum to be treated, so far as I understand
the case, is not in a state of mortification, neither is it
fixed by adhesions within the sac. The directions given
for its excision lead us to infer that it lies loosely in the
sac, and that it must be secured by an assistant to pre-
vent the danger of its retrocession into the abdominal
cavity before the ligatures are applied to the bleeding
18
138 ENTERO-EPIPLOCELE.
vessels. After this, the remaining omentum " is to be
returned into the abdomen with its divided surface ap-
pHed to the mouth of the sac, from which the hgatures
are suspended." Here let me inquire, what security has
the surgeon, that the omentum thus returned, will not
recede from the mouth of the sac, and carry the liga-
tures within the abdominal cavity. When we consider
the powerful peristaltic action, in the arch of the colon,
to which the omentum is attached, in every act of de-
jection, I can discover no rational ground of hope for
its being retained precisely at the mouth of the sac.
If it be deemed expedient by many surgeons, to stitch
the mesentery to the side of the wound in case of a
mortified spot on the bowel, to prevent its retrocession,
it seems to me very hazardous to trust a portion of
omentum, which is not fixed by adhesion to the sac,
and which is subjected to all the chances of displace-
ment from the motions of the intestine.
If the recommendation of Cooper had alluded simply
to a portion of irreducible omentum, which had been
firmly fixed by old adhesions to the hernial sac, the
safety of the practice could be more readily admitted.
My own limited experience supplies a case of this kind,
in which a portion of omentum in this condition was
excised, a ligature was applied, and the patient reco-
vered.
ENTERO-EPIPLOCELE. 139
CASE XXIII.
Entero-Epiplocele — Expatriated Omentum — Excision —
Cure,
5th mo. 10th, 1828. I was called this day, in con-
sultation with my friend Dr. Janney, to see the widow
H., about sixty years of age. She has had a tumour in
the right groin for twenty years, and says that she has
been frequently subject to colic, which has generally
been relieved in a few hours. Her present attack oc-
curred suddenly, at about 3 o'clock, P. M., on the 7th
inst., since which she has been extremely ill, with pain,
constipation, and vomiting. Her countenance was
sunken and dejected; her pulse feeble; her hands and
wrists cool, and dark coloured; her tongue moist; and
she had but little tenderness of the abdomen, and none
of the hernial tumour. Her intellect was clear, and she
could not believe that the tumour in the groin had any
thing to do with her complaint. However, on receiving
a very positive assurance of our belief that all her pre-
sent distress was the result of incarceration of the
bowel, she finally consented to the 0[)eration. With the
assistance of Dr. Janney, and three of my pupils, I pro-
ceeded, between five and six o'clock, P. M., the patient
having previously taken an opiate. The tumour was
of considerable size and an oval form. I made a crucial
incision, dissected up the flaps, and soon came down
on a hernial sac. It was remarkably thin and trans-
parent. I think I never saw one more so. The parts
underneath appeared very much like intestine, and
140 ENTERO-EPIPLOCELE.
although I had previously expressed the opinion that
the hernia would prove to be entero-epiplocele, I now
really thought that I had been mistaken. The sac was
opened readily. No fluid, or scarcely any, was con-
tained in it. On laying it open in the usual manner, a
considerable mass of old, expatriated omentum was
exposed: but just as I had anticipated, there was no
appearance of the intestine. I now opened through the
crown of the arch of omentum, and finally found a
small slip of intestine that had been completely con-
cealed by the omentum. The intestine was very dark
coloured, but entirely free from cadaverous smell. I
now felt for the stricture, found it very firm, and divided
it with the bistoury. I then passed my finger by the
side of the bowel into the abdomen. I cut off the prin-
cipal part of the expatriated omentum, and secured
one vessel by ligature, but did not attempt to return
any portion into the abdomen. The patient did not
lose one ounce of blood, and the operation was com-
pleted in about five minutes. At the close, she ap-
peared rather fainty. We put her to bed, and placed
pillows under her knees; directed quietness; one grain
of opium every four or six hours. Two of my pupils
remained constantly with this patient — who was ex-
tremely ill — and as will be perceived, a note was made
of her symptoms every four hours. — Nighty 12 o'clock.
Pulse 108. The patient has been tolerably quiet since
the operation, and has slept pretty well since 9 o'clock,
when she took one grain of opium. Her bowels have
been opened two or three times, and she has also dis-
charged flatus. Diet of barley-water and gruel in small
quantities, and frequently.
11th. Morning, 11 o'clock. The patient has awak-
ENTERO-EPII'LOCELE. 141
ened from are freshing sleep of three hours, nearly. She
is somewhat thirsty. Pulse 100, with strength and ful-
ness. — Evenings 6 o'clock. Dr. Janney saw her. Some
reaction took place about 2 o'clock, P. M., which was
diminished by applying cool vinegar to the face and
arms. She has had occasional sleep. She took a se-
cond grain of opium at 4 o'clock. Her pulse was now
104; her abdomen tympanitic. She has just had an
evacuation. — 8 o'clock. Pulse 106; skin natural. She
complains of a sense of tightness at the pit of the sto-
mach. She has had some sleep. Directed castor oil oj.
to be taken every four hours, with mint-tea. — 10 o'clock.
Her bowels have been opened; one grain of opium ex-
hibited. — 11 o'clock. Pulse 108, and full. She has had
another evacuation; is restless, and not inclined to
sleep. — 12 o'clock at night. Pulse 120; skin rather hot
and dry. She is wakeful, says she feels faint, and com-
plains of excessive thirst.
12th. Mornings near 3 o'clock. Pulse 124, and irri-
tated. Her bowels were opened at 2 o'clock, the dis-
charge was quite natural. She has thirst, and dozes at
intervals; skin husky. — Near 5 o'clock. The last dose
of oil was ejected. This medicine was discontinued.
Pulse 126, and irritated; tongue furred, and florid at
the point. The patient is very restless. — 7 o'clock. Pulse
126, and fuller. The bowels have been freely opened,
and the patient is not quite so restless. She complains
of occasional pains in the epigastrium. — 9 o'clock. Dr.
Janney and myself saw the patient together, and exa-
mined the wound, which presented a favourable aspect.
Ordered an application of fresh lard. The abdomen is
perfectly soft; pulse 120; tongue slightly furred. She
has had a copious evacuation, and complains of insa-
142 ENTERO-EPIPLOCELE.
tiable thirst. Ordered lime-water and milk every half
hour, and sodaic powders. If restless, fifteen drops of
laudanum to be given. Gum arabic in solution, as a
drink. — 12 o'clock, Night. The patient has slept well
since 10 o'clock. Pulse 128. She complains of uneasi-
ness at the pit of the stomach,
13th. Dr. Janney saw the patient. Pulse 132; tongue
furred and dry; thirst very great. Flatus discharged
from the bowels. There is slight tenderness at the um-
bilicus. The uneasiness at the epigastrium continues.
The patient states that she had been affected with faint-
ness, and a disposition to vomit, for a week previous
to her attack. A mixture of camphorated spirits and
tincture of opium was ordered to be applied warm, on
flannel, to the stomach. — Evenijig^ 4 o'clock. Pulse the
same. The patient is very restless. She took fifteen
drops of laudanum. — 6 o'clock. Pulse 130. She has
has had a little sleep, and copious natural evacuations.
Half past 7 o'clock. Dr. Janney and myself saw the
patient together. Pulse 130; tongue furred, but moist;
tenderness of the epigastrium upon pressure; the thirst
continues. Directed fifteen or thirty drops of laudanum
according to the restlessness, every four or six hours.
A blister to the epigastrium. Neutral mixture to be
given every two hours, if the pulse continues high, and
skin hot. Chicken-water — 9 o'clock. The blister ap-
plied, and the neutral mixture given. — Near 10 o'clock.
Fifteen drops of laudanum given.
14th. Mornings past 3 o'clock. Skin hot and dry;
tongue furred and dry; pulse 135. She has slept well
for about an hour. — 7 o'clock. The patient's condition
has been pretty uniform since half past 4 o'clock this
morning. Pulse between 111 and 113; tongue moist;
ENTERO-EPIPLOCELE. 143
skin less hot. She passes her urine freely, and says that
the uneasy sensation at the epigastrium has left her.
The abdomen is soft, and there is no more pain on
pressure than usual. She has had two evacuations. —
Half past 8 o'clock. Dr. Janney and myself saw the
patient. Pulse 112; the abdomen soft; the wound looks
well; tongue somewhat dry, but disposed to clean at
the tip; skin rather warm. — Evening, 4 o'clock. The
patient is quite comfortable. She has slept tolerably
well at intervals, and complains of no uneasiness at the
epigastrium. Tongue and skin as before; pulse 113.
7 o'clock, P. M. Dr. Janney and myself called to see
the patient. Pulse 120. The thirst continues. She com-
plains chiefly of her uneasy position. Directed rennet-
whey, &c.
15th. Morning, 4 o'clock. The patient passed the
night quite easily and composedly, sleeping almost con-
stantly after 12 o'clock. She has taken the neutral mix-
ture and the rennet-whey. She has had no discharge
from the bowels. Pulse 112. No pain on pressure. No
change in tongue or skin. — Half past 8 o'clock. Pulse
106. Directed castor oil oss. every four hours, which
produced a free and natural evacuation. — Eveiiing,
half past 4 o'clock. An exacerbation of fever came on.
7 o'clock. Dr. Janney and myself called. Found the
abdomen soft, and the tongue partly cleaned. Thirst
diminished. Directed some nourishment, and the omis-
sion of the saline mixture, unless the skin is hot and
dry. To commence, early in the morning, with an in-
fusion of serpentaria and chamomile, a small wine-
glassful to be taken every hour.
16th. Morning, 8 o'clock. Pulse 108; tongue clean
and moist. The patient passed a comfortable night. She
144 ENTERO-EPIPLOCELE.
took twenty drops of laudanum. — Evening, 7 o'clock.
Pulse and tongue in the same condition. Every symp-
tom favourable. She has had a free, natural evacua-
tion without medicine, and has a desire for food, such
as asparagus, &c.
17th. Morning, 8 o'clock. Pulse 100; tongue as yes-
terday. The patient passed the night comfortably with-
out laudanum. — Evening. She is still in the same con-
dition.
18th. Pulse 106; tongue as before. The patient rested
well, and had a free evacuation this morning. She had
taken a spoonful of oil at bed time. The infusion of
chamomile and serpentaria was rejected by the sto-
mach this morning, and was therefore omitted. Ordered
infusion of columbo and orange peel, a wdne-glassful
every two hours. The granulations in the wound ap-
pear white and not healthy. Directed bark to be sprin-
kled on them.
19th. The patient says she feels well. Pulse 96.
Tongue natural.
20th. Morning. Her bowels are free. — Evening. Pulse
100. Her medicine has not agreed with her stomach.
Ordered infusion of bark, a wine-glassful every two
hours, to be taken early in the morning.
21st. Pulse 96. The patient rested well. Her bowels
were moved at 12 o'clock. — Evening. Pulse 80, and
every thing favourable.
6th mo. 4th. The patient has been doing well since
the last date, and to-day the ligature came away by
twisting it. This patient recovered completely.
Remark.
The unpleasant symptoms in this case may have been
ENTEKO-EPIPLOCELE. 145
produced by the ligature; but on this point my opinion
is not decided.
It is a source of reocret to observe a number of writers,
some of them of the highest character, all following in
the same train; all recommending the practice of ex-
cising the omentum, and applying ligatures to the
bleeding vessels, without giving one instance to prove
the safety of the plan. Is there not a danger, by this
course, of a proposition, vague in the first instance, be-
ing converted by frequent repetition into a settled rule
of practice, until melancholy experience may prove its
unsoundness and danger?
The question then arises, what is to be done with
expatriated omentum? If a small portion presents itself,
and can be conveniently cut off, no danger need be
apprehended from hemorrhage; but when a large mass
is encountered, it has generally been my practice to
allow it to remain undisturbed.
The following cases furnish examples of this condi-
tion of the omentum, and of the treatment to be pur-
sued.
CASE XXIV.
Entero-Epiploccle — Exjmtriated Omentum — Excision —
Cure.
lOth mo. 28th, 1826. I was called this day in consul-
tation Avith Dr. Ruan, to see the wife of A. S. The
patient is about thirty-six years of age. About seven
years ago, after a great etTort in lifting, she became
19
146 ENTERO-EPIPLOCELE.
affected with a femoral hernia on the left side. The
protruded parts have never been completely reduced
since that time. She has had several spells of colic, as
she calls it, with an increase in the size of the tumour,
but they have always gone off, until the present attack,
which has had forty-eight hours continuance. The
tumour is pretty large.
Dr. Ruan was called last evening. He bled her ad
deliquium, and attempted the taxis. He says that there
was a considerable reduction in the size of the tumour
in consequence of this attempt. Laxative injections
were given, and he ordered an opiate enema; but it
seems that she passed a most wretched night. She has
vomited up every thing from the commencement of the
attack; and her bowels are obstinately confined. I
found her in great distress, with extreme tenderness in
the tumour, and in the abdomen; complaining of severe
pain in the stomach, extending toward the bottom of
the abdomen. The pain appeared to come on in pa-
roxysms, during which she suffered excessively. She
rejects anodynes given by the mouth, and, what is truly
remarkable, anodyne injections pass away from her im-
mediately.
The operation was proposed, and Drs. Physick and
Barton were called in consultatiou. We gave her
opium by the rectum, and tried some in the form of
pill. We then prepared for the operation, which I per-
formed about fifty-two hours after the commencement
of the strangulation, assisted by my medical friends.
The patient was placed on a table. By flexing the
thigh on the pelvis, it was found that the skin over the
tumour was quite flaccid. Dr. Physick aided in pinching it
up, and I then passed the sharp-pointed bistoury through
ENTERO-EPIPLOCELE. 147
it, with the back of the instrument turned toward the
tumour, and, at one stroke, made a longitudinal incision
nearly long enough for my purpose. 1 did not make
a crucial incision in this case. By the aid of the director
and bistoury I soon laid bare, as we supposed, the her-
nial sac; and, pinching up a small portion with the dis-
secting forceps, cautiously made an opening into it.
What appeared to be the sac was then laid open in the
usual manner; but there was still a thin layer, resem-
bling cellular membrane, laying over the strangulated
parts. This was opened in the same manner, and
then, for the first time, a small quantity of fluid escaped.
The omentum was now exposed to view, and, on- turn-
ing it aside, a small slip of intestine, of a dark choco-
late colour, appeared; hut there was no cadaverous smell.
I passed down my finger, and feeling a very tight stric-
ture, I very carefully divided it in a direction upward
and a little inward, with my blunt-pointed bistoury,
which was guarded as usual, with a rag wrapped round
the greater part of the blade.
I now returned the intestine into the abdomen; but
what was to be done with the omentum? I remarked
to my friends that it had been so long expatriated that
I should be afraid to put it into the belly. It was,
therefore, determined to cut the greater part of it away,
which I did, removing also, in the same manner, a por-
tion of the old sac, M'hich stuck up in the wound like a
piece of buckram. There was but little bleeding. I
pushed the remaining portion of the omentum towards
the opening from the abdomen, hoping that it would
inflame, and plug up the aperture, so as to form a natu-
ral truss.
Just before the completion of the operation, the wound
148 ENTERO-EPIPLOCELE.
was suddenly filled with what at first appeared to be
blood; but, on closer inspection, it proved to be nothing
more than the same kind of fluid usually contained in
the sac, which, mixing with a httle blood from the
omentum, really gave, at first, the idea of considerable
hemorrhage.
Two sutures were used in dressing the wound, leav-
ing a small opening between the edges, at its most
dependant part. The patient was placed on her back,
in bed, with her knees bent and supported by pillows.
One grain of opium was given, and directed to be re-
repeated every four or six hours, according to her rest-
lessness.
Evening. I saw her between five and six o'clock, and
again after ten o'clock to-night. She is greatly relieved
from pain, although she still has some slight paroxysms.
She has considerable thirst, and vomits occasionally,
after drinking. She attributes the sickness to the opium,
which, she says, always disagrees with her. She takes
barley-water. Her pulse is 100 in the minute. The tem-
perature of her skin is nearly natural, and her tongue
is slightly furred. She has less pain on pressure, in her
abdomen. Her countenance and spirits appear good.
Directed'fifteen drops of the black drop every four or
six hours, if restless; but, if composed, the anodyne to
be omitted.
29th. Morning, 9 o'clock. The patient slept well
through the night. Her countenance is good; pulse 80,
soft aud full; abdomen flaccid, and its tenderness greatly
diminished. Directed half a pint of boiling water to be
poured on sup. tart, potass. Sss. et manna ij. A table-
spoonful to be given frequently till it operates; and in
case of pain, fifteen drops of the black drop to be also
ENTERO-EPIPLOCELE. 149
given. — Evening, 5 o'clock. As I was absent from the
city, Dr. Barton saw the patient for me. Her abdomen
was tumid from distension of the bladder. The catheter
was introduced, and a large quantity of urine drawn off.
Pulse and skin natural. The dose of crem. tartar and
manna was increased to a wine-glassful, with directions
that if it did not operate by 10 o'clock, she should take
a wine-glassful of an infusion of senna -every hour.
30th. Morning, 10 o'clock. Dr. Barton again visited
the patient. The crem. tartar produced great pain in
the bowels, followed by an evacuation at i past 9
o'clock last evening, and, as she was restless, fifteen
drops of black drop were given her at 10 o'clock. She
rested well through the night. Her pulse and skin this
morning showed some slight febrile excitement. Her
retention of urine still continued, but, as there was no
desire to evacuate it, the catheter was not introduced.
Serum, slightly tinged with blood, is discharged from
the wound; this is supposed by Dr. Barton to come from
the cavity of the abdomen. The Doctor directed a
bread-and-milk poultice to be applied over the wound,
and that her diet should be barley-water. — Evening, 8
o'clock. Dr. Ruan and myself visited the patient this
evening. Pulse 80; skin natural. I drew off the urine
with the catheter. The patient passes flatus freely.
31st. Morning, 9 o'clock. The patient has passed a
very good night, except that she was troubled with
flatulency. Pulse 88; skin and countenance natural.
There has been no evacuation from the bowels since
last report. I directed her to take an ounce of castor
oil, and to drink oatmeal-gruel. The catheter has to be
used regularl}^, morning and evening. — Evening, 8
o'clock. The patient has not yet had any evacuation.
150 ENTERO-EPIPLOCELE.
11th mo. 2d. The tenderness of the abdomen is nearly
gone. Directed castor oil ^i"> ^^^ for diet, oatmeal-
gruel, tapioca, &c.
3d. Pulse 80, soft and full; tongue clean; skin natural.
The wound has partly healed by the first intention, and
the remainder is suppurating. The patient is permitted
to lie on her side, and to eat the soft part of an oyster
every hour.
4th. Pulse 80; skin natural; tongue clean. The pa-
tient has had three evacuations since the last report.
The abdomen is flaccid, and entirely free from pain on
pressure. This patient perfectly recovered.
CASE XXV.
Strangulated Femoral Hernia — Dark and hardened
Omentum — Excision — Cure.
11th mo. 29th, 1823. A poor widow, aged about
sixty-four years, was attacked about a week ago, with
strangulated hernia, which was regarded by her medical
attendant as colic, until, finding his remedies fail, he
was led, after several days, to make a closer investiga-
tion of the case; when he discovered a tumour in her
left groin.
I saw her, for the first time, yesterday afternoon and
evening. Her stomach had been retentive for two days
previously; it even retained castor oil very well; but her
bowels were obstinately constipated. There was no
tension or unusual tenderness of the belly, although she
complained of pain and distress high up in the abdo-
ENTERO-EPIPLOCELE.
151
men. Her pulse was rather frequent; but her tongue
and countenance had not an unfavourable appearance.
At our last visit in the evening, the patient seemed to
expect an evacuation from the bowels, and we concluded
to exhibit some castor oil, with an opiate, and to leave
the case till morning.
On visiting her this morning, we found that she had
vomited the oil, and her whole aspect was more unfa-
vourable. I therefore gave her an opiate, and proceeded
to the operation, assisted by Drs. Uhler and Hewson.
The tumour was rather large for a femoral hernia. I
made a crucial incision, dissected back the corners, and
divided the layers of fascia3 with considerable expedition,
by the aid of the director, assisted occasionally by the
handle of the scalpel. The sac was opened in the usual
manner, and a small portion of bloody fluid escaped.
On enlarging the orifice, some very dark-coloured and
hard omentum came into view, one portion of which
felt almost like bone; but no intestine was apparent. I
turned aside the omentum, and then discovered a small
portion of very dark-coloured bowel. As the omentum
was considerably in the way, I cut it off. It did not
bleed, and yet there was not the least cadaverous smell
from the sac. On examining the stricture, it was found
very firm. I very cautiously divided it with the blunt-
pointed bistoury, until I could pass my finger into the
abdomen. It was now found that the omentum about
the stricture was firmly adherent to the intestine.
With my finger, I cautiously separated the adhe-
sions, and returned the parts into the abdomen. I also
separated some adhesions within the cavity. The wound
was dressed with adhesive strips. The patient bore the
operation well.
152 ENTERO-EPIPLOCELE.
Evening. The patient presents rather a discouraging
appearance. Her countenance is more sunken, and her
tongue somewhat dark. She has slept almost constantly
since the operation. Pulse firm, about 100. There is
still great uneasiness in the abdomen, with weakness
of stomach, and considerable inclination to vomit. The
bowels have not been opened.
30th. Morning. Pulse 100, full and soft; temperature
natural; tongue moist, furred, and less dark; counte-
nance improved. The patient vomited twice during
the night, and also discharged flatus per anum twice.
She slept well, but still complains of pain, and a sense
of fulness in the stomach and abdomen. She took one
grain of opium, and three-fourths of a Seidlitz powder,
during the night. Directed one-fourth of a Seidlitz
powder to be taken every half hour. — Evening. Pulse
112, less full and regular. The patient has slept
considerably, has vomited twice, and has had one fecal
discharge. The pain in the abdomen continues.
12th mo. 1st. The patient has had five evacuations.
She took one grain of opium since last visit. Pulse 100;
tongue moist. Pressure on the abdomen gives her pain,
but the belly is flaccid. — Evening. Pulse 96; tongue
furred; no tension of the abdomen. The last stool took
place about 9 o'clock this morning. The Seidlitz pow-
der has been given regularly, and the patient has taken
one grain of opium. She complains of great pain about
the umbilicus. Ordered to continue the Seidlitz powder
until the bowels are moved, and to take a grain of
opium every six hours, if restless.
2d. Pulse 100; tongue somewhat dark and dry; face
flushed; some tension of the abdomen, but no pain. The
patient complained of difficulty in passing urine, and the
ENTEllO-EPll'LOCELli. 153
catheter was introduced. Ordered to omit the opium
and continue theSeidhtz powder. — Evening. Pulse 112;
tongue moist; skin natural; tension and pain in the ab-
domen; no stool. Ordered castor oil, a table-spoonful
every two hours, and an opiate, if restless.
3d. Pulse, tongue, and skin continue in the same
state. The patient vomited once in the night, passes
urine freely, and has had natural stools. The abdomen
is less tense, but is still painful. Treatment continued.
Evening. The patient has passed a considerable amount
of flatus, but has had no stool. The pain in the abdo-
men slight. Treatment continued, and an enema of
flaxseed-tea directed.
4th. Pulse 100; skin natural; tongue somewhat dry.
The patient has had three stools. The pain and tension
of the abdomen slight. Treatment continued. Ordered
a diet of chicken-water, whey, &c. The wound dressed
with simple cerate.
5th. Pulse 112; skin and tongue as at last visit. The
patient has had about five discharges from the bowels.
The tension of the abdomen is diminished, but the pain
continues. Ordered to omit the oil, but to continue the
Seidlitz powder, and if necessary, the opiate. — Evening.
Tension and pain diminished; pulse 100. The patient
has had several stools without medicine. Treatment
continued.
6th. Pulse 100; skin natural; tongue rather dark
and dry; slight pain in the umbilical region; very little
tension of the abdomen. The patient had one stool
last evening. She rested well through the night. The
wound is suppurating moderately. Ordered the Seid-
litz powder to be taken three times a day. Treatment
and regiincn continued.
20
154 ENTERO-EPIPLOCELE.
7th. Pulse 100; the tension and pain have ceased;
the bowels act freely. Treatment continued.
8th. Pulse 90; wound suppurating moderately. Every
thing looking favourably. Treatment continued.
This patient recovered perfectly.
CASE XXVI.
Irreducible Enter o-Epiplocele — Stercoraceous Vomiting
Operation — Death.
2d mo. 15th, 1819. I was called by Dr. Dewees to
see, with him, a widow lady aged sixty-seven years.
She had been afflicted with hernia since the birth of her
first child, which must have been many years ago. She
represented that she had always, since that time, had a
tumour in the part, which was generally about the size
of an Ggg, but sometimes larger. She had been labour-
ing under strangulation since the evening of the tenth
instant, when, in a fit of coughing, the part became
strangulated. Dr. Dewees had ascertained the existence
of hernia, a few hours before I was called, and imme-
diately requested a consultation. On examination, at
this time, he found the matter which she had thrown
from her stomach, stercoraceous.
On my first visit I was struck with the peculiar situa-
tion of the tumour. It appeared to be in the upper part
of the thigh, extending across it, and I could trace it
along the internal abdominal ring, as is usual in ingui-
nal hernia. I was strongly inclined to believe that it
ENTERO-EPIPLOCELE. 155
was femoral, but the size of the tumour exceeded that
of any femoral hernia I had ever seen before.
After dehberating on the case, Dr. Dewees and my-
self concluded to recommend the operation at once^ and
it was most readily submitted to by the patient. An
anodyne enema was given, and two grains of opium
were administered by the mouth. At this time the pa-
tient had a tolerably good pulse, and no cold or clammy
sweats; her tongue was rather dark; and her bowels
somewhat tender to the touch.
I made a crucial incision through the integuments,
and dissected up the four flaps; then, principally by the
aid of the grooved director, I divided several layers of
fascia, and after dissecting carefully downward, I at
last opened the sac, and exposed a large mass of omen-
tum. I found considerable difficulty in this part of the
operation, in consequence of there being no fluid be-
tween the sac and the omentum. After I had fairly un-
covered the omentum, still greater difficulties assailed
me; for I found this mass firmly impacted together by
pretty strong bands of adhesion: there was no appear-
ance of intestine. I had no doubt of the existence of
strangulated bowel, but the question was, where to find
it; and I concluded that the only way to get at it was
to lay open the omentum. After having penetrated for
some depth through the centre of the mass, I at last
found an aperture, through which I pushed my finger,
and felt the bowel, contained as it were, in another sac.
I now dissected through the omentum more freely, and
brought a portion of intestine into view. It was of a
very dark colour. Some fluid, of a bloody colour, was
contained in this inner sac, hut it was free from the cada-
verous smell of a mortified part. I pushed my finger
156 ENTERO-EPIPLOCELE.
down by the side of the bowel and felt a stricture, which
I divided inwards, in a direction towards the pubis, and
pretty readily returned the bowel into the abdominal
cavity.
The vomiting ceased, and her distress left her im-
mediately afterwards, yet her strength gradually de-
clined. She was much disposed to coma. Surgical
aid, in this case, came too late; for, though the patient
was certainly relieved by the operation, in forty-eight
hours afterwards she died. The omentum was per-
mitted to remain where we found it. No post mortem
examination took place.
CASE XXVII.
Irreducible Enter o-Epiplocele — Stercoraceoiis Vomiting —
Operation — Intestine black — Death,
11th mo. 20th, 1822. I was called this day, in con-
sultation with Drs. Griffith and Hewson, to see the
Widow L., an elderly woman who had been affected
with an irreducible femoral hernia of the left side, for
nineteen years. It was unusually large, and of an ob-
long shape, extending, I suppose, at least eight or ten
inches from above downward, and about six inches in
width. At its lower part it formed an irregular apex.
On the morning of the 17th instant, as she rose from
her bed, she was suddenly attacked with severe pain,
and an additional descent and sudden strangulation
took place. Immediately after this, she had an evacua-
ENTERO-EPIPLOCELE. 157
tion from the bowels. Various attempts were made by
Drs. Griffith and liewson to reduce the part, but with-
out success; and ultimately I was called in consultation.
When I saw the patient, her countenance was good
and lively; her tongue moist, slightly furred, and rather
whitish than dark. The abdomen was soft and natural,
and was very little sensible to pressure, except in the
vicinity of the stricture. The tumour was painful when
pressed. She complained of general distress. Pulse
about 130 in the minute. On examining the vomited
contents of the stomach, they were found completely
stercoraceous. This patient reminded me very forcibly
of the preceding case. On examining the tumour, I
thought I very distinctly perceived a fluctuation. As
the patient at once consented to the operation. Dr.
Hewson, who was the operator, commenced the neces-
sary preparations. A full dose of laudanum was given.
A crucial incision was made over the most promi-
nent part of the tumour, but was not extended over the
whole tumour. After dividing the integuments, Dr. H.
soon came down upon a firm fascia, and there appeared
a small point, rising rather above the general level,
which, on being touched, gave the impression to the
fincer of a fluctuation underneath. It was concluded
to open the sac at this point, which was cautiously
done.
The sac was found to be remarkably thick. All the
layers of fascia) appeared to be completely identified,
and had formed an investment of the thickness of a
quarter of an inch. This, I presume, depended on the
Ions: continuation of the disease in an irreducible form.
When the sac was laid open, a mass of omentum was
displayed, through which several small apertures were
158 ENTERO-EPIPLOCELE.
discovered, and through these apertures passed a small
portion of bloody-coloured serum, such as we often
find in a hernial sac.
The case was less embarrassing than that just de-
tailed, because the serous and bloody fluid which
passed through the apertures in the omentum clearly
indicated the course that ought to be pursued. The
Doctor broke through the arch formed by the omentum,
and brought into view a portion of intestine that, by
candle-light^ appeared quite hlack and mortified; but it
was destitute of any cadaverous fetor. The stricture
was now divided directly upward, so that the finger
could be passed into the cavity of the abdomen, by
the side of the bowel; and, with rather more difficulty
than common, the intestine was reduced. The patient
supported the operation very well. The omentum was
permitted to remain undisturbed.
21st. I saw her again in consultation. She had
passed a more comfortable night than might have been
expected, but still the bowels were not opened, and
yet the sufferings of the patient were greatly dimi-
nished.
22d. We found her this morning, in articulo mortis.
She has had no evacuation of the bowels since the
operation.
This patient lived, contrary to all expectation, for
several days longer, but finally died.
MORTIFIED OMENTUM.
The several methods of treatment, which relate to
the excision of expatriated omentum, have also been
ENTERO-EriPLOCELE. 159
proposed, when this part is in a state of mortification.
These have been so fully examined in the preceding
section, that it is deemed unnecessary to recapitulate
them. Believing that the excision of a large mass of
omentum is attended with risk by any method, I have
pursued the practice of leaving the mortified portion
in the wound, relying upon the efforts of nature to effect
its separation from the sound parts. This process may
be assisted by the gradual, yet very gentle pressure of
a ligature around the root of the diseased mass, in
such a manner that the patient may at any moment
unloose it, if he should feel pain or sickness.
This plan has been strongly recommended by Hey,
and pursued by him successfully in three cases detailed
in his valuable work.
A case fell under my care some years ago, in which
this practice was successfully adopted. It was pub-
lished in the Eclectic Repertory, Vol. I. p. 13, from
which it has been extracted.
CASE XXVIIT.
Entero-Epiplocele — Mortified Omentum — SlougMng of
the mortified mass — Recovered.
On the third day of the Third month (March,) 1810,
my immediate attendance in consultation was requested
by my friend Dr. Samuel Tucker, of Burlington, N. J.
The patient was a farmer of middle age, who led a
laborious life, was of temperate habits, and the parent
of six children.
160 ENTERO-EPIPLOCELE.
He had been occasionally afflicted with scrotal her-
nia for fifteen years, but had never worn a truss, or
disclosed his situation to any person. When it proved
troublesome, he had been in the practice of reducing it
ivithout difficulty.
On the morning of the 28th of Second month, while
in the act of lifting a heavy log, a portion of the abdo-
minal contents was suddenly protruded through the
ring, and became strangulated. He had an alvine dis-
charge immediately after.
From the period that Dr. Tucker first saw him, until
I was called, he had diligently resorted to the most ap-
proved plans of reduction; viz., taxis, venesection,
applications of ice to the tumour, tobacco injections,
warm bath, &c. &c., but all without effect.
When I saw him, his chief distress appeared to arise
from vomiting and hiccough; the latter always occurred
after drinking. His pulse was remarkably tranquil;
tongue moist, and but slightly furred; no tension or ten-
derness in the abdomen; and it was not until the latter
part of that day that he was sensible of darting pains,
which occasionally extended from the strictured part
towards the abdominal cavity. The tumour was of con-
siderable size, and rather firm to the touch.
As Dr. Tucker had decided on the necessity of the
operation previously to sending for me, it only remained
for us to obtain the patient's consent; but this was
rather difficult, for he was very indecisive, sometimes
partly consenting, and then refusing. It was night
when I visited him, and under all circumstances, it ap-
peared as if nothing could be done until daylight. The
mildness of his symptoms reconciled us more readily
to this conclusion. He had slept well the preceding
ENTERO-EPIPLOCELE. 161
night without an anodyne. A small enema containing
tincture of opium was given him, and directions were
left to repeat it in an hour, if the patient should be rest-
less.
Dr. Tucker and one of his friends saw him about
sunrise. He walked from his bed-chamber into the
common room, handed chairs, invited them to sit down,
said he had passed a good night, and in fact had quite
abandoned the idea of having any operation performed.
I saw him soon after; and we again endeavoured to
explain to him the extreme danger of his situation, and
he at last consented to the operation.
An opiate was exhibited, and he was placed on a
table. An incision was made through the skin, suffi-
ciently large to allow a free examination of the parts
about the neck of the hernial sac. While carefully
dissecting through the integuments, three arteries were
divided and secured by ligatures; the largest was found
running directly across and just below the neck of the
tumour. Several tendinous stricturing bands were
brought into view and divided; but after every apparent
external cause of stricture was removed, the prolapsed
parts were still irreducible. The incision was extended
alono- the scrotum nearly to the bottom of the tumour,
and the hernial sac was laid open. A fluid of a bloody
colour issued from it.
It was now evident that the chief seat of the stricture
was in the neck of the sac; it was contracted firmlv
round the protruded parts. The tip of my finger was
introduced as a director for the blunt-pointed bistoury,
with which it was readily divided.
Its contents consisted chiefly of omentum, of which
21
162 ENTERO-EPIPLOCELE.
there was a much larger portion than would have been
imagined from the size of the tumour. I should guess
there might have been nearly eight ounces. Along with
this, and lying in the very centre of the omentum, was
a portion of intestine, which passed about an inch and
a half beyond the stricture. It appeared nearly natu-
ral, but the omentum was in a very different state; a
considerable part of it was sphacelated, particularly its
exterior surface, which was quite black, and its vessels
were greatly distended with coagulated blood. Some
other portions were of a light mahogany colour, and
were brittle when placed between the fingers. The cen-
tral part of the mass was chiefly natural.
The intestine was speedily reduced; but for reasons
to be hereafter assigned, the omentum was left in the
wound. Three sutures were used in uniting the lower
part of the incision, so as to close it as nearly as was
practicable without compressing the omentum. Soft and
light dressings were applied over the whole.
The patient appeared faint about the close of the
operation; he was presented with a little wine and wa-
ter, but it was rejected by the stomach. He was now
placed in bed, and soon sunk into an easy and profound
sleep. He was in this state when I left him, about an
hour and a half after the operation. His pulse was fuller
and yet free from tension.
A very light diet of chicken-liquor, barley-water, &c.
was directed. Also ol. ricini, half an ounce every two
hours until it operated.
In a letter from Dr. Tucker, he reports:
" Our patient rested well the night after the opera-
tion. He took four or five spoonfuls of castor oil; it
ENTEUO-EPIPLOCELE. 163
began to operate at four o'clock in the morning, and
relieved his bowels five or six times. I left directions in
the evening, that if the oil operated excessively, it
should be checked by taking five drops of laudanum.
His wife gave him the laudanum about noon the next
day.
" Monday evening, 5th. His bowels had not been
moved since noon. I directed him to take the oil again
until it operated. No fever; pulse 75.
" Tuesday morning, 6th. Rested well last night; no
fever or pain; pulse 75. Castor oil has operated twice.
" Evening — the same.
" Wednesday morning. Did not sleep well last night.
When disposed to sleep, started, which gave him some
pain, and prevented its recurrence for some time. He
does not, however, appear to be worse. No fever;
pulse 75. Takes chicken-broth, barley-water, &c."
On the 11th of the month I visited him in company
with Dr. Tucker. He was then perfectly free from pain
and fever; no tension or tenderness in the abdomen;
union, by the first intention, had taken place in the part
of the wound approximated by sutures; and the living
omentum situated within the wound, and in contact
with the edges, appeared to have adhered to them, and
to have closed the cavity of the abdomen.
Subsequent information from Dr. Tucker enables me
to state, that on the 18th the last portion of the un-
sound omentum sloughed away, leaving the living part
divided into two distinct portions, suspended from the
wound by two necks.
On the 21st, a ligature was applied to one half the
omentum, in the manner recommended by Hey; viz.,
164 ENTERO-EPIPLOCELE.
rather slight at first, and increasing gradually as the
patient could bear it. On the 25th it Avas perfectly
black and flaccid, and was removed by scissors. On the
26th a ligature was applied to the remainder, and at
this time the wound had cicatrized, except where the
tumour was suspended from it. In both cases there was
a considerable oozing of blood after the omentum be-
came black, but surrounding the part with lint put a
stop to it. On the fifth day from the application of the
last ligature the tumour was removed.
In about five weeks after the operation the patient
began to walk about the house; and in eight weeks
he resumed his agricultural avocations, and ploughed
a large field for the reception of Indian corn. Since
this period he has enjoyed very excellent health, and
wears a truss to guard him from future danger.
It has been urged against this practice, that the
sloughing of a large mass of omentum may cause great
derangement of the parts within the abdominal cavity.
That the adhesions formed about the ring, may draw
the stomach and arch of the colon out of their natural
position, and the patient may ever after be subject to
those, afflictions which depend on a displacement of
vital organs.
Instances are on record of patients who have been
obliged to walk with the body bent forward, from this
cause; and who have been obliged to take their meals
in this posture, to prevent the immediate rejection of
their food.
These cases are, however, exceedingly rare, and are
not even noticed by many experienced authors who
ENTERO-EPIPLOCELE. 165
have written on hernia. Numerous instances of irre-
ducible hernia present themselves, in which large por-
tions of omentum have been firmly fixed in a hernial
sac for many years, without producing these distress-
ing consequences. Is it not rational to conclude, that
in a large majority of cases of this kind, the system
exerts that wonderful power with which it is endued, of
eluding difficulties, and becoming inured to conditions
which a priori we might suppose highly injurious?
It is not intended, however, to convey the idea, that
this practice is entirely free from objections; but that
it is attended with less risk than any other plan which
has been proposed.
It has been previously stated, that a portion of bowel
frequently descends behind an irreducible omental rup-
ture, and there becomes strangulated. If the surgeon
should succeed in reducing the intestine by taxis, the
omentum which remains in the sac may still be sub-
jected to a stricture, by which its vitality will be de-
stroyed. Under these circumstances, an abscess is
formed, through which the diseased mass is discharged.
The inflammation which attends this process, may
produce adhesions about the neck of the sac by which
it will be effectually closed, and a radical cure thus
effected.
A case of this description fell under the care of my
friend and former pupil. Dr. Thomas Yardley. An
account of which he has kindly furnished me for pub-
lication.
166 ENTERO-EPIPLOCELE.
CASE XXIX.
Gangrenous Omentum discharged by Abscess — Radical
Cure.
"3<?mo. 20th, 1826. About noon this day I was called to
visit S. C, a widow, aged about thirty-five years. I found
her complaining of intense pain in the cavity of the
abdomen, attended by stercoraceous vomiting and con-
stipation of the bowels. These symptoms induced me
immediately to suspect strangulated hernia, and on in-
quiry, I found that, though unacquainted with the name
and nature of a ' rupture,' she had observed a lump
about the size of a walnut in her left groin for the last
six years, ever since the birth of her youngest child.
She stated that it gave her little or no inconvenience,
except in damp weather, and when she was much fa-
tigued. About three years since, she had an attack
similar to the present; it, however, lasted only twenty-
four hours, and went off by taking oil, laudanum, &c.
without the advice or assistance of a physician.
" The train of symptoms, under which I found her
suffering, commenced on the 16th instant. She had been
stooping down, washing the floor of the house, and on
raising up, was suddenly seized with a very violent pain
across the lower part of the abdomen. The rectum was
almost immediately evacuated, and vomiting soon su-
pervened. To allay the vomiting and relieve the pain,
a variety of medicines, such as oil, salts, laudanum, 6zc.
were administered; but without effect. Being in indi-
gent circumstances, she was deterred from employing a
ENTERO-EPIPLOCELE. 167
physician till the 20th instant, when I, as one of the
physicians of the Northern Dispensary, was desired to
visit her.
" On being permitted to examine the parts, I found a
femoral hernia about the size of a hen's egg. After
placing the patient in a proper position, I resorted to
the taxis, and in a few minutes, had the pleasure of feel-
ing the tumour give way, and a gurgling noise, pro-
duced by the return of the intestine, was distinctly
heard.
" The pecuhar and distressing pain attending a stran-
gulated bowel ceased; and as the omentum had been
so long excluded from the cavity of the abdomen, I
deemed it imprudent to prolong the efforts to restore
it. I accordingly directed a small dose of calomel and
jalap, and left the patient, with instructions that she
should be kept as quiet as possible.
" In the evening, I found her with slight fever, but
entirely free from the intense pain which she had pre-
viously complained of. The vomiting had ceased, but
her bowels had not been evacuated. I directed a set
of Seidlitz powders to be taken in divided doses at in-
tervals of half an hour, and a large cathartic injection
to be administered immediately, and repeated in an
hour if it did not produce the desired effect.
" The next morning the nurse reported that the injec-
tion produced a copious discharge from the bowels, and
that the patient had passed a very comfortable night.
" On the succeeding morning the nurse called my
attention to an extensive and painful inflammation di-
rectly over the hernial tumour. As I was conscious
that no rude efforts had been made to return the omen-
tum, I was at first somewhat surprised; but on exam-
168 ENTERO-EPIPLOCELE.
ining the parts, I could readily perceive, by the peculiar
crepitation, that there was a gaseous fluid contained
in the cellular texture beneath; and feeling satisfied
that it was derived from no other source than the pro-
truded omentum that still remained strangulated, I di-
rected that a poultice should be applied to the part, and
placed the woman in such a position as to relax the
integuments as much as possible.
" The application of the poultice was, in a short time,
followed by the discharge of a yellow and extremely
offensive matter; several pieces of dead omentum after-
wards passed out, and the inflammation of the sur-
rounding parts subsided. Some difficulty was expe-
rienced in healing the sinus which remained, but it was
effected by the introduction of lint dipped in tincture
of myrrh.
" This woman has remained ever since entirely free
from rupture, and enjoys excellent health, though she
continues to work very hard."
INFLAMED OMENTUM.
A portion of bowel and omentum may suddenly de-
scend in the same sac, and immediately become stran-
gulated. Efforts at reduction failing, an operation is
resorted to; the contents of the sac are found in a state
of high and recent inflammation, and the only course
that presents itself is, to return the parts into the abdo-
men. In doing this, the patient is subjected to great risk,
either from the subsequent mortification of the omental
mass, or from the occurrence of severe and fatal peri-
toneal inflammation. Some years ago the following
case occurred to me, in which I was obliged to incur
these risks.
ENTERO-EPIPLOCELE. 169
CASE XXX.
Enter o-Epiplocele — Omentum Liflamed — Return into
Cavity — Death.
5th mo. 11th, 1820. I was called in haste to Bustle-
ton, in consultation with Drs. Worthington and Smith,
to visit a young man residing at the stage-house. I
learned that on the morning of the 10th instant, at
about 10 o'clock, the bowel had descended, for the first
time in his life, in consequence of violent exertion, and
had immediately become strangulated. The taxis and
other means of reduction had been faithfully tried by
Dr. Worthington, but without success.
As the symptoms were urgent, I proposed the imme-
diate resort to an operation, to which the patient as-
sented. Pulv. opii. gr. ij. were exhibited, the parts were
shaved, and he was placed upon the table. I proceeded
to the operation, assisted by his physicians and one of
my pupils.
An incision was commenced above the ring, and car-
ried down to the lower part of the scrotum; the dissec-
tion was cautiously pursued until the most prominent
part of the sac was exposed. The sac contained a small
portion of fluid, and was opened without difficulty.
When the opening was sufficiently enlarged to allow
my finger to pass, my first impression was that the sac
contained coagulated blood; but on closer examination,
I found that a large mass of omentum was closely im-
pacted in a very small space, and the whole of its exte-
rior surface was studded with small points of coagu-
22
170 ENTERO-EPIPLOCELE.
lated blood, which were so close to each other as to
convey the impression of the whole mass being blood,
as I had first supposed.
On examining the omentum, I was at first inclined to
the opinion that it was mortified, owing to its very dark
colour', but on puncturing a vein on its surface, blood
escaped, which induced me to suppose that it was not.
To ascertain the fact more certainly, we adopted the
plan of covering the parts with a bladder filled with
warm water, as in case xv. p. 95.
The bladder was kept applied for about twenty mi-
nutes, when it was perfectly evident that the circulation
was going on, and that the omentum was highly in-
flamed. A small portion of intestine was strangulated;
its colour was very dark, but we did not consider it in a
state of gangrene. After dividing the stricture, the
bowel was readily returned. But the disposal of the
omentum was now to be considered; this part had cer-
tainly suffered great contusion from some cause or
other. I was inclined to believe that the eflforts at taxis
might have caused the efliision of blood upon the sur-
face of the omental ball — on the same principle that
water is pressed from a sponge, when it is forcibly
grasped in the hand.
To cut oflf this mass in its vascular and inflamed
condition, would subject the patient to very great ha-
zard from hemorrhage, after its return into the abdo-
men, unless ligatures had been applied to arrest it;
while the ligatures would, in my judgment, more cer-
tainly induce fatal peritonitis, than the return of the
inflamed mass. Besides, it was not probable that the
excision of that portion which presented externally,
would prevent the extension of inflammation to the
ENTERO-EPIPLOCELE. 171
parts within. To allow a living inflamed mass to re-
main in the wound, as in a case of mortified omentum,
appeared very objectionable.
It was therefore concluded, that its return into the
abdominal cavity, although manifestly attended with
great danger, would subject the patient to less risk than
any other method. To effect this, the opening at the
ring was enlarged, and the part readily restored. The
wound was not drawn together as usual, by strips and
sutures, but dressed very lightly with simple cerate.
I left the case under the full conviction that dan-
gerous inflammation would ensue; and advised my me-
dical friends to allow the patient to rest for a few hours,
to recover from the fatigue of the operation; and if reac-
tion occurred, to pursue a rigid antiphlogistic course.
It was agreed to keep the bowels open with castor oil,
and to restrict his diet to barley-water.
I received regular accounts from Dr. Smith of the
progress of the case.
Soon after the operation, he became delirious and
feverish, symptoms of peritonitis, followed by singultus,
supervened, and he died on the evening of the 21st inst,,
ten days after the operation.
Dissection,
On opening the abdomen and pelvis, the commence-
ment of the colon presented a very dark appearance for
the space of about six inches, and at one point it was
quite black. The coats of the bowel were abraded
in several places, and at several spots small sloughs
had separated, so that flatus rushed out on handling
the surrounding bowel. The other parts of the bowels
appeared nearly natural.
172 ^ ENTERO-EPIPLOCELE.
That portion of omentum which had been return-
ed, was still inflamed, and adhered in a solid mass
to the surrounding parts. No appearance of gangrene
was discovered in any part of the omentum, though the
parts around the returned portion were slightly in-
flamed.
The pelvis contained about a pint of turbid fluid,
resembling pus diluted with water, and slightly tinged
with blood. No unpleasant odour was observed in any
part of the examination.
CHAPTER VII.
CONCEALED HERNIA.
Every candid practitioner, who has had much expe-
rience in the treatment of hernia, will admit that cases
of a very dangerous character, are sometimes involved
in great obscurity, and may elude his vigilance.
Hence the utmost caution is required to detect those
concealed cases, which, under the common form of co-
lic, may continue unsuspected, until the death of the
patient, followed by a post mortem examination, reveals
the true state of the case.
Having had a share of painful experience in this form
of the disease, I have been led to increased minuteness
in my examinations, and have been enabled to afford
relief by an operation, in several cases, which would
probably have escaped detection, had I not been par-
ticularly watchful.
The most common seat of mischief, in these cases,
is at the internal ring. The principal part of a protruded
intestine may be returned by taxis, and yet a very small
portion may be detained at the internal ring, forming a
very slight prominence or fulness at this point, scarcely
observable, and yet sufficient to keep up fatal strangu-
lation. A very curious case is related by Dr. Dorsey,
in which an old hernial sac formed the seat of stric-
ture. A small process of sac, which had been reduced,
and was almost within the abdomen, extended through
174 CONCEALED HERNIA.
the upper ring; into this a portion of the ileum had
been forced, and became strangulated. In this case an
operation was performed, but the patient died a few
hours afterwards; and on a post mortem examination,
the strangulated intestine was found mortified.*
In the case to be detailed in this section, which I saw
m consultation with my departed friend Dr. Perkin, it
would really appear, from his account of the dissection,
as if the strictured bowel had been, from some cause
or other, deprived of its contents, whereby its internal
surfaces were brought into contact, and the promi-
nence of the tumour thus destroyed. There is an ob-
scurity about this case, which I cannot comprehend,
and which I must leave the reader to explain for him-
self. There can be no doubt that the patient died with
the symptoms of strangulated hernia.
CASE XXXI.
Concealed Hernia — Strictured Bowel Flaccid — Died,
9th mo. 1818. I was lately called in consultation with
Dr. Perkin, to visit J. E., a middle-aged man, corder at
Race street wharf. I was informed, that four days pre-
vious to my visit, he had been seized with constipation
of the bowels, pain, and vomiting. All efforts to relieve
him had utterly failed. My first question was, has he
been afflicted with rupture? The Doctor said he had
examined the groins, but could discover nothing —
though the patient had been the subject of hernia.
* Dorsey's Surgery, vol. ii. p. 49.
CONCEALED HERNIA.
175
I now made a very careful examination, and could
find no tumour. The patient himself believed that his
rupture had no concern in his symptoms.
We met again in a few hours: and found that the
patient had been sinking rapidly. At our next visit, a
few hours after, he had a cold, clammy sweat, with a
feeble pulse; tense and tumid abdomen; an absence of
pain. His stomach now retained every thing that was
given.
I again examined for hernia, being convinced that
the symptoms strongly indicated it; but I was satisfied
that nothing had passed the abdominal ring. I then
remarked to Dr. Perkin, that perhaps strangulation
might exist at the internal ring; but as there was no
tumefaction to guide us to the part, we did not consider
it justifiable to cut down into the abdomen, merely upon
conjecture. A few hours after this visit, the poor man
died.
Dissection.
Dr. Perkin dissected the body, and informed me, that
he found a hernial sac below the ring, but it did not
descend low in the scrotum. About five inches of in-
testine was found in the sac in a state of strangulation;
it was of a very dark colour, but not actually morti-
fied. The bowels above the stricture were enormously
distended with flatus, but the portion within the sac
was flaccid, and its sides were in contact.
176 CONCEALED HERNIA.
CASE XXXII.
Strangulated Inguinal Hernia — Apparent deduction by
Taxis — Death.
9th mo. 20th, 1818. A poor woman was brought into
the Hospital in the evening, labouring under the symp-
toms of strangulated hernia. The hernia was inguinal,
in the left side, and had been strangulated for two
days. The tumour was not large; the abdomen rather
tumid and tender on pressure; tongue nearly natural;
pulse pretty good. She had been attended previous to
her admission by a very respectable physician, who,
from her account, had made various efforts to reduce
the parts. Among other plans, a tobacco enema had
been used, which made her very sick, and procured
some evacuation.
I directed two grains of opium, and had preparations
made for an operation. Drs. Hartshorne and Dorsey
met me in about two hours. On inquiry, it was found
that a portion of the rupture generally remained in the
sac, and the patient thought that a part had been re-
duced by her physician out of the house.
Dr. Klapp, who had attended her, was sent for, but
was not at home. As it was late in the evening, and
the symptoms were not so urgent as in many cases,
my colleagues proposed delaying the operation until
morning. It was agreed to put the patient in a warm
bath, and to apply gradual pressure by a succession of
smoothing irons, allowed to remain on the part, and
changed as fast as they became warm.
CONCEALED HERNIA. 177
Next morning, 2l6t. We found that the tumour had
disappeared. It had been reduced by Dr. B. H. Coates,
the house surgeon, early in the morning. Dr. C. has
kindly assisted me in making out a report of the case,
and states his recollections on this point, in the follow-
ing terms:
" The smoothing irons were continued on the part
all night, as the woman informed me; and at my visit
next morning, which must have been about 7 o'clock, I
found to my extreme gratification, though, as it subse-
quently proved, in vain, that I could apparently reduce
the tumour. It passed up, along the abdominal canal,
without any resistance; and I observed an absence of
the usual rounded form and elastic resiliency of intesti-
nal hernias; and, finally, that it appeared not completely
to enter the abdomen, a slight fulness remaining at the
upper part of the abdominal canal, extending down-
wards from the region of the internal ring. From these
circumstances I inferred the tumour to be omental; and
judged that there remained no stricture."
22d. Found the patient labouring under the symp-
toms of strangulated hernia, and evidently sinking. On
examining the groin, the rupture appeared to be re-
duced. I desired one of the house pupils to call on one or
both of my colleagues, and request them to see the case,
and if they believed that any thing could be done for
the relief of the patient, to call a consultation.
She was seen by Dr. Hartshorne, who agreed with
me, that nothing further could be done. The poor wo-
man died early on the morning of the 24th.
A post mortem examination was made by Dr.Coates.
I was not present, but have received from Dr. C. the
followhig account of the dissection.
23
178 CONCEALED HERNIA.
"A crucial incision was made. As I raised that angle
of the abdominal parietes which contained the part
affected, I saw the fold of intestine falling out of the
internal ring, by its own weight and continuity, not-
withstanding I made a sudden effort to prevent it.
" It was thus evident that there was no strangulation
at the time. There was an indentation round the fold
of intestine, which embraced its whole width. I after-
wards applied a thong of buckskin leather loosely
around the place of constriction, in such a manner as
to maintain the original form of the intestine, and pre-
served the fold, distended and thus secured, in spirits,
together with the separated sac. I have seen this pre-
paration within the last two or three years, although I
have either lost it in removing, or given it away.
" I remember examining the patient very carefully
for peritoneal inflammation. The peritoneal surface
was perfectly healthy. There was no adhesion or effu-
sion of any kind, either in the cavity of the abdomen,
or in the sac; nor the least coagulating lymph adher-
ing to the included fold, to the stricture, or to the lining
of the sac. The intestine was not reddened, except a
little irregular, dark, mottled appearance, which I took
to be settling of blood. There was not any large col-
lection of feces above the point included in the stric-
ture; so that I gained the impression that the passage
of the contents of the intestine was not obstructed."
These two cases made a very strong impression on
my mind, and induced me to believe that an incarce-
rated bowel might escape detection, unless the examina-
tion was very carefully conducted. In the case of J. E., Dr.
Perkin and myself both examined with more than ordi-
CONCEALED HERNIA. 179
nary care, and could discover nothing. And in the case
of the woman at the Hospital, knowing that there had
been a tumour, and finding it had disappeared, it was
a fair inference that the hernia was reduced. The re-
sult of these cases were to me a source of great unea-
siness; and I determined, if another obscure case pre-
sented itself, to watch it very narrowly.
Not a great while after this, such an opportunity was
afforded; and I attribute the successful issue of the case,
in a great measure, to my previous experience.
CASE XXXIII.
Strangulated Inguinal Hernia — Stricture at Internal
ring — Small tumour externally — Strangulated eight
days — Recovered.
In the early part of the summer of 1819, my friend
Dr. E. A. Atlee sent one of his students to me to bor-
row a syringe. The student stated that he wished to
give an injection to a patient whose bowels M^ere ob-
stinately constipated. From his account I was im-
pressed with an idea, that it was a case of hernia, and
requested him to state to Dr. Atlee my apprehen-
sions, and to desire him to make an examination of
the groins. The student delivered my message, and not
long afterward, I received the following history of the
case from Dr. Atlee. On the 30th of 5th mo. the patient
was attacked with symptoms of severe colic. The usual
remedies were resorted to without affording relief. On
the 31st the Doctor suspected hernia, asked the patient
180 CONCEALED HERNIA.
if there was any swelling in the groin, and was an-
swered in the negative.
The constipation was obstinate, the stomach rejected
almost every thing, and he complained of acute pain
over the abdomen, with tenderness on pressure.
Bhsters were applied to the abdomen, wrists, and
ankles, and cathartics and enemata were freely given,
without procuring stools. These symptoms continued
until 6th mo. 6th, — eight days from the commencement
of the attack, — when the true state of the case was dis-
oovered. On the receipt of my message. Dr. A. made a
minute examination of the groins, and thought he dis-
covered something suspicious. The prominence was so
slight that it could not be detected by the eye, and
what is remarkable, it had eluded observation, though
the patient was examined while naked, and lying in a
warm bath. The Doctor now thought he could discover
a small tumour above the external abdominal ring. At
this stage of the case I was requested to see the patient
in consultation. On a minute examination 1 could feel
a small tumour at the internal ring. Dr. Hewson was
sent for, and met us very soon. On examination he
could feel a tumour, and agreed with us, that the ope-
ration should be immediately performed. I made an
incision directly over the tumour, and exposed the
tendon of the external oblique muscle. This was di-
vided by the director and bistoury, until the hernial
sac was brought into view; this was opened, and
a portion of intestine was discovered, of a very
dark colour, but not mortified. The stricture was not
very firm, or I presume mortification would have oc-
curred much sooner. I divided the stricture and re-
turned the bowel. The sides of the wound were now
CONCEALED HERNIA. 181
approximated by the interrupted suture, and secured by
adhesive strips, and the dressing completed by a com-
press and bandage. — 12, P. M. Pulse 85 in the minute,
full and tense; considerable heat in the head, throbbing
of temporal artery, and delirium. Blood was taken from
the arm, which afforded immediate relief.
7th. Noon. Pulse 75; is easy, and inclinded to sleep;
thirst abated. Complains of occasional jumping pain in
the wound. Affection of the head entirely ceased. —
Evening. Has taken about oiv. of ol. ricini; bowels not
yet opened; stomach settled; abdomen not distended
or painful; pulse 80. Had an injection late in the even-
ing.
8th. Morning, Pulse about 80; has had no evacua-
tion since injection. — Evening. Has had two or three
plentiful evacuations of fecal matter; somewhat deli-
rious; pulse full and strong, 82 in the minute; abdomen
flaccid.
9th. Passed a restless night, with considerable deli-
rium. Took 3j. of Glauber salts, with an opiate during
the night. This morning another dose of salts was given
which produced two free evacuations. The head was
shaved, and cold water repeatedly applied; the body
was sponged with cold water. Rennet whey was pre-
scribed for drink. Another ounce of salts was given at
noon. — Evening. Has had three small evacuations; the
abdomen is free from pain. Has had throbbing of the
carotids, with some aberration of mind through the
day. Another dose of salts was prescribed. A wine-
glassful of a strong infusion of hops was prescribed
every two hours. 11, P. M. Patient somewhat coma-
tose, with throbbing of the carotids. Apply ice to the
head.
182 CONCEALED HERNIA.
10th. Morning. Has had a recurrence of the affection
of the head. Cups were apphed, and afforded relief.
Patient is now pretty free from dehrium, and is inchned
to doze. Tongue is heavily loaded. — 10, P. M. Pulse
was bounding, about 75. Has had a bihous evacuation,
and is free from delirium.
11th. Morning. Patient considerably improved; pulse
nearly natural; bowels opened several times during the
day.
12th, Has had a good night. The wound has a
healthy appearance, except a slough in the centre.
From this time the patient rapidly recovered.
CASE XXXIV.
Strangulated Scrotal Hernia — Apparent Reduction — Re-
covered.
nth mo. 25th, 1821. I was called this day in con-
sultation with Dr. Knight, to visit J. S., a young man
about twenty-eight or thirty years of age. He had lately
recovered from a three months illness on the river Sus-
quehanna, with the epidemic autumnal fever. He has
been afflicted with hernia for many years; it has been
several times strangulated, but he has always been able
to reduce it.
The present attack commenced on the evening of
the 23d instant. When Dr. Knight was called, he found
a strangulated scrotal hernia of considerable size on
the right side. The patient was in great pain. He tried
the taxis, bled him, and gave him a dose of opium. On
CONCEALED HERNIA. 183
the succeeding day he directed a cathartic, ice to the
tumour, &c. The result was that the hernia appeared
to be reduced, and the Doctor anticipated no danger.
The patient stated that there was always more fulness
on that side than on the other. The Doctor was pre-
vented by a case of midwifery, from seeing him again
until morning; when he was alarmed at finding the pa-
tient's bowels still constipated, and that he had sterco-
raceous vomiting and singultus. In consequence of this
state of things my attendance in consultation was de-
sired.
On examination I readily distinguished the spermatic
cord. There was rather a preternatural fulness in the
course of the abdominal ring, and some tenderness on
pressure, particularly about the internal ring. But as
the statement of the patient showed that there was al-
ways some fulness of this part, the surgeon might easily
have been deceived into the belief that the hernia had
been reduced, had it not been for the presence of
marked evidences of strangulation. We recommended
the immediate removal of the patient to the Hospital.
He requested two hours to consider of it. At the con-
clusion of that time, three grains of opium were given,
and he was removed in a carriage. Just before the
operation, thirty drops of laudanum were exhibited, and
I proceeded, Drs. Hartshorne and Price being present
in consultation.
I made a free incision through the integuments, be-
ginning above the internal ring and extending down on
the scrotum. I dissected down until the tendon of the
external oblique muscle was exposed. In doing this,
an artery had to be secured. Aided by the director and
bistoury, I now divided the parts, from above down-
184 CONCEALED HERNIA.
ward, and soon laid bare a hernial sac, distended with
a Httle fluid. I opened it in the usual manner, and
exposed the testicle. The hernia was congenital. We now
discovered a piece of intestine just peeping at the mouth
of the external ring. Its colour was good. I divided the
parts slightly, and could pass my finger freely round the
bowel, but found that it would not return. I now pushed
my finger along the course of the canal till I came to
the internal ring; there I distinctly felt the stricture,
and divided it directly upward with Cooper's blunt bis-
toury, (my own not being at hand,) and reduced the
intestine with great ease. We then brought the lips of
the wound together with adhesive plaster, and two
stitches on the scrotum, and the patient was put to bed.
We directed his knees to be bent and supported; gave
him a little wine and water; and ordered him thirty
drops of laudanum every six hours, and barley-water
for nourishment.
26th. The patient has passed a good night. The sin-
gultus and vomiting have ceased. He appears now
quite comfortable, but he has complained of great thirst
through the night. His abdomen is very tumid, and
tympanitic; his pulse 112; and his tongue furred. Or-
dered castor oil, a table-spoonful every two hours. —
Evening. The oil has not operated, but the patient has
passed flatus. Directed the oil to be continued. The
abdomen is still very tympanitic, though somewhat
less tumid.
27th. The patient has had free evacuations from his
bowels after having taken eight doses of the oil. He is
evidently better; has less thirst; stomach settled; no
singultus; his tongue is still furred, and rather dark. The
tympanitis has subsided. Pulse 90 in the morning; 96
CONCEALED HERNIA. 185
in the evening. Directed to continue tlie barley-water;
to use molasses and water, or plain water for drink; and
if restless, an opiate.
28th. The patient is evidently improving. He has
had an evacuation from his bowels, and the tympanitis
has subsided. Pulse 84; tongue still furred and rather
dark. Directed a diet of rye mush and molasses, or
oatmeal gruel.
29th. Morning. The patient is still improving. His
tongue is disposed to become clean. Directed ol. ricini
5SS. every two hours until the bowels are moved. — Even-
ing. Three doses of the oil have produced two stools, and
the tongue is becoming clean. Pulse 84. The patient is
in fine spirits.
This patient recovered and was discharged cured.
24
CHAPTER Vlll.
UMBILICAL HERNIA.
My experience in strangulated umbilical hernia may
be considered as limited. I have, however, witnessed
a few cases which may be worthy of record.
A very interesting case of this form of the disease
came under my notice in consultation with Drs. Dorsey
and Cathrall, while I was surgeon to the Almshouse
hospital. The strangulation of the bowel was caused
by a number of bands passing across the umbilical open-
ing in various directions. These occasioned considera-
ble difficulty in the operation — the patient died. Dr.
Dorsey performed the operation, and thus notices the
case in his work on surgery:
" In one case of umbilical hernia, I was greatly em- .
barrassed by finding the intestine strangulated in seve-
ral different places by bands passing from the omentum
to the intestine. These bands, which were elongated
adhesions of a very firm texture, converted the hernial
sac into a cavity resembling the ventricles of the heart;
the morbid productions extending, like the chorda? ten-
dineae, from one part of the cavity to another; under
several of these cords, portions of the ileum had been
strangulated, and by cautious dissection, I succeeded in
liberating, and returning into the abdomen, the recently
protruded parts."
UMBILICAL HERNIA. 187
A case of umbilical rupture of a peculiar character
came under my care in the spring of 1817, which I will
relate from my notes.
CASE XXXV.
Umbilical Hernia — Mortification of the Integuments —
Death.
3d mo. 8th, 1817. Dr. Hollingshead, of Moorestown,
New Jersey, came over to see me, and requested my
immediate attendance on one of his patients in Eves-
ham. We crossed the Delaware with considerable dif-
ficulty on account of the ice, and arrived at the house
just before night.
The patient was a farmer's wife, of middle age, sub-
ject to umbilical hernia for about twenty years, but was
always able to reduce it until the morning of the 5th
instant, when it became strangulated. I found the in-
teguments covering the tumour perfectly livid, and in
a state of mortification; this foreclosed all reasonable
prospect of success from an operation.
At the request of the Doctor I communicated to the
patient a candid statement of her awful situation. The
extremely slender prospect of success from an opera-
tion was fairly presented to her. It could not, there-
fore, be encouraged, and yet if desired, this last effort
should not be refused. As she appeared to have con-
siderable strength, and with her husband decided in
favour of the operation, it was performed. An incision
was carefully made through the skin; no bleeding fol-
188 UMBILICAL HERNIA.
lowed, and the part appeared as entirely insensible to
pain as a piece of black leather. I divided the stric-
ture with a blunt-pointed bistoury. The hernial sac
contained a portion of omentum and small intestine in
a state of complete mortification.
There was a hardness in the integuments round the
margin of the hernia for several inches, like a cake of
placenta, caused it is supposed by inflammation.
The adhesions were so firm, that I could not draw
out into view any portion of living bowel. Little else
remained after liberating the parts, than to rest the
case upon the efforts of nature; but all was unavailing,
she died on the morning of the tenth instant.
I once attended an old black woman in Middle alley,
a Dispensary patient, who had a large umbilical rup-
ture in a state of strangulation, with gangrene of the
integuments. In this case no operation was attempted,
and the patient died.
A most extraordinary case of this disease fell under
my observation some years ago, in company with my
friend Dr. Hartshorne.
The patient was a female who was attended by the
late Dr. Cleaver, who called upon us to assist him in
the operation; the hernia was small. A stricture was
divided, and a portion of bowel returned. The case
went on very favourably for several days, when most
unexpectedly the patient was attacked with tetanus,
and soon died.
I have not ascertained that Dr. C. left any note of
the case, but so far as my recollection of the circum-
stances may be relied on, the facts were these. On ex-
amination after death, a small portion of intestine was
UMBILICAL HERNIA. 189
found in a mortified state, without the usual evidences of
adhesion from previous inflammation. The impression
left on my mind is, that owing to some peculiar con-
dition of the constitution of this patient, the usual order
of nature was interrupted, and the dead bowel instead
of producing surrounding inflammation, had acted as
an irritant to the nervous system, causing tetanic
spasm, and death.
Dr. Hartshorne informs me, that he has a distinct
recollection of the case, and of its termination in teta-
nus, and states, that he once operated on a woman at
the Pennsylvania Hospital, for strangulated umbilical
hernia, who was strongly threatened with tetanus, but
who finally recovered.
The occurrence of umbilical rupture in early infancy
is not uncommon, but I believe it will be found that in
a large proportion of these cases, nature performs a
radical cure, and thus renders it unnecessary for the sur-
geon to interfere. This opinion is confirmed by the ex-
perience of Dr. Physick. In a late conversation with
him, he stated to my son, that in the whole course of
his practice, he had seldom experienced any trouble in
the treatment of these cases, and had never considered
it necessary to perform any operation for their cure. It
is only requisite in ordinary cases, to direct the mother
or nurse to place the hand over the tumour, when the
child cries, and to keep the bowels open. If these direc-
tions are not eflfectual in retaining the bowel, the appli-
cation of a graduated compress, secured by strips of
sticking plaster, will be found useful.
Dessault has recommended a plan for the radical
cure of umbilical hernia, which he has frequently per-
formed, and considers quite safe. I pursued this plan
190 UMBILICAL HERNIA.
many years ago, in a case in which I was concerned
with Drs. Wistar and Physick. The case resulted fa-
vourably, though not without considerable anxiety on
our part. It is detailed in this place, not with a view of
recommending the operation, but to show that it is not,
in every instance, so trifling an affair as one might be
led to conclude.
With my present experience, I would not repeat the
operation in a similar case, but would prefer relying on
the efforts of nature, with an observance of the direc-
tions just noticed.
CASE XXXVI.
Umbilical Hernia — Radical Cure.
lOth mo. 31st, 1810. S. A., aged about twenty-two
months, has had an umbilical hernia from his birth.
This day, in consultation with Drs. Wistar and Phy-
sick, I commenced an attempt to produce a radical cure
according to the plan of Dessault. Dr. Wistar took the
tumour between his fingers, having first returned the
contents of the sac. I now passed a ligature three times
round the base of the integuments and the sac, and
secured it at each turn by a double knot. The ligature
was only drawn tight enough to give an inconsiderable
degree of pain; the child did not cry.
11th mo. 1st. The child has not appeared to sustain
any inconvenience. His bowels are rather lax. He is
kept on a soft vegetable diet, especially rye mush. The
tumour looks a little faded in colour, and rather
UMBILICAL HERNIA. 191
slirunkeii. It now appears as if the parts were disposed
to form another sac behind the one which has been
inclosed in the hgature; but as pressure on this pro-
truded part does not cause it to return, there is reason
to beheve that it is occasioned by the cellular mem-
brane beins a little inflamed and thickened.
2d. The patient is still free from pain and uneasiness.
On inquiry, it appears that he rubbed off the ligature
this morning: an inflamed ring marks the place where
it was applied, and the integuments containing the sac
are certainly a little thickened. While fixing him for
the purpose of applying the ligature again, he became
restless and cried; but it really appears as if the pro-
trusion of the bow el is not so great as before the first
application.
The integuments were now taken hold of by Dr.
Wistar, as before, and I passed the ligature rather be-
low the place where the previous one had been applied,
and secured it by three turns, with a double knot on
each turn, drawing it considerably tighter than before.
This ligature gave rather more pain than the first, but
not a great deal.
3d. The ligature retains its situation very well. The
lower part of the tumour appears of a purplish hue.
The tumour itself is rather tense. The patient does
not appear to sustain any material inconvenience; he
plays about, and is very lively.
4th. The tumour seemed a little shrunken, and it was
concluded to pass a ligature sufficiently tight to inter-
cept the circulation. This was accordingly done, with-
out removing the other ligature. It gave considerable
momentary pain, but it appeared soon over.
5th. The tumour looks black. A vesication filled
192 UMBILICAL HEIINIA.
with bloody-coloured serum has been formed near its
base.
8th. The ligature retains its situation. The vesicated
part has dried completely, and the whole surface
of the tumour is of a light-purplish colour. It appears
to be rather hard. On puncturing it with a lancet, it
did not bleed, but the tumour has not shrunk.
11th. The exterior covering of the tumour appears
to have sloughed away, leaving a living surface beneath,
from which some pus escapes; and pus is also formed
about the ligature. Some slight inflammation is appa-
rent in the skin near the tumour; for this I directed
a poultice containing some lead-water.*
15th. Morning. The poultice has been continued un-
til this day. The ligature has gradually cut through
the greater part of the integuments, leaving the sac
nearly bare, and a considerable cavity in the integu-
ments. This has not a pleasant appearance. I now passed
the last ligature round the tumour, and drew it quite
tight. On visiting him in the afterrioon, for the purpose
of applying adhesive strips, so as to give as much sup-
port as possible to the parts, I found that the integu-
ments had gradually contracted since the poultice had
been removed, and I believe that the poultice was cer-
tainly the cause of the parts looking so relaxed, and
the ulcer so large, as they did in the morning. The
child still enjoys fine health and spirits.
* About the time of the application of the poultice, the extent of the
ulcerated surface caused me considerable uneasiness; had the child been
attacked with severe cough, or long-continued crying, there would, I be-
lieve, have been some risk of a rupture of the new-formed parts, and con-
sequent protrusion of the bowels.
UMBILICAL HERNIA. 193
16tli. The ligature and tumour came off this morn-
ing, leaving a small aperture and granulations over its
surface. A piece of adhesive plaster was applied over
the part, compresses placed on it, and a bandage car-
ried over the whole, to complete the dressing.
Cicatrization took place very soon, and the cure has
proved complete.
25
CHAPTER IX.
STRANGULATION WITHIN THE ABDOMEN.
The symptoms which mark a violent attack of stran-
gulated hernia may exist, without a protrusion at any
point. The obscurity of these cases baffles all efforts at
relief, and the physician is obliged to look on, and wit-
ness a fatal termination.
Several cases of this description have fallen under
my observation; in two of these a post mortem examina-
tion was permitted, and the cause satisfactorily ascer-
tained. In another instance, which occurred some years
ago, the event was equally distressing, though the cause
of the symptoms remains a mystery. The patient was
a remarkably fine-looking young man from Kentucky,
tall, yet very muscular and strong. He had come to the
city to purchase a stock of goods, and was suddenly
seized, in a state of high health, with the symptoms of
strangulated hernia. Dr. Physick was called to visit
him, suspected hernia, and made a minute examination,
but could discover no protrusion.
He requested me to see the patient in consulta-
tion; the examination was carefully repeated by both
of us, but we could discover nothing to justify an ope-
ration. He died on the fifth day from his attack. To
our great regret we were not permitted to make a post
mortem examination; though from the symptoms there
STRANGULATION WITHIN THE ABDOMEN. 195
can scarcely be a doubt, that his death was caused by-
some mechanical obstruction in the bowels.
In the two cases in which a post mortem examina-
tion took place, it will be perceived, that the accumu-
lation of flatus in the bowels had the principal agency
in keeping up the obstruction.
This fact I consider important, as pointing to the
only method of treatment which seems to offer any
prospect of relief under such circumstances.
If a cord of omentum, thrown across the abdomen,
be pressed by the distended bowel to its utmost point of
tension, it is evident that, as the accumulation of flatus
increases, the sides of the bowel will be opposed by this
tightened cord, and its internal surfaces be brought into
contact. The greater the distension, the more firmly
will the bowel be secured, and the more complete will
be the obstruction. The only way in which parts thus
strangulated can be relieved, is by withdrawing the
flatus from the bow els, and thus restoring their freedom
of motion. In another case, I should attempt to effect
this by the gum-elastic tube, and exhausting syringe,
employed as recommended in the remarks which follow
case xxxviii., at the close of this chapter.
CASE XXXVII.
Constipation — Obstruction produced by Diseased Omen-
tum — Death,
\st mo. 3d, 1831. M. B., aged about forty-eight years,
a large, corpulent woman, the mother of twelve children,
196 STRANGULATION
was suddenly attacked in the market, on the morning
of the 1st instant, with violent abdominal pain, sickness
of stomach, and vomiting.
Dr. Beasley saw her soon after the attack. She in-
formed him that her bowels had been constipated for
two days, and that she had taken nothing that morning
to which she could refer the attack; her breakfast had
been light and simple. The Doctor endeavoured to
allay the violent pain by opiates, and administered
calomel, infus. senna, and ol. ricini, to act upon the
bowels. She had been twice bled, and was placed in a
warm bath.
On the evening of the 2d, I was called in consulta-
tion. All attempts to act upon the bowels had failed,
though the stomach was more settled. From the history
of the case I immediately suspected strangulated her-
nia, but on a careful examination no tumour could be
discovered. I encouraged Dr. Beasely to persist in the
use of castor oil, and advised anodyne enemata to calm
the restlessness of the patient. There was at this time
considerable tenderness on pressure over the abdomen,
extending around the umbilicus, and from the left, to-
ward the right side. Her pulse was feeble, and the skin
cool. Before daylight, on the morning of the 3d, she
died.
Dissection,
Dr. Beasley made a post mortem examination, at
which I was present. A portion of the omentum was
formed into a rope or cord, which extended from the
left to the right side, dipped down into the pelvis, and
was firmly attached to the peritoneum across the sym-
physis pubis. Involved in this cord we found the left
WITHIN THE ABDOMEN. 197
ovarium with an hydatid attached to it. The bov/els
were monstrously distended with flatus. The cord of
omentum drawn thus firmly across the abdomen, acted
hke a ligature upon the distended intestines, and the
portions which came wdthin its range, were pressed
together, thus forming a complete obstruction in the
passage; and the greater the distension, the firmer was
the pressure of the cord.
We suspected that this state of things must have
been caused by a previous attack of peritoneal inflam-
mation, probably depending on puerperal lever. On in-
quiry of the husband we ascertained, that a few days
after the birth of one of her children, ten years ago,
she was attacked with violent fever, and pain in the
abdomen, which confined her for a long time. Since
this time she had been subject to occasional attacks
of disease in the abdomen. The ovarium contained a
considerable quantity of hair of a whitish appearance.
CASE XXXVIII.
Strangulated Scrotal Hernia — Stricture divided — Ob-
struction continued from adhesionswithin the abdomen^
and distension of bowels.
During my pupilage with Dr. Wistar, a highly inte-
resting case of strangulated hernia occurred in his
practice. The following is the history of the case:
James , an apprentice to J. S., aged about six-
teen years, had been for several years the subject of a
198 STRANGULATION
scrotal hernia. As he was able to return the bowel
without difficulty, he never made it known to his mas-
ter, and had not worn a truss. On the evening of the
3d instant, he was unable to return the bowel as usual,
and on the following morning Dr. Griffitts saw him:
he directed v. s., warm bath, purgative injections, &c.,
and endeavoured to reduce the tumour by taxis. In the
evening he was bled again, and the other remedies w-ere
continued. Several days elapsed, during which time Dr.
Currie was called in consultation; the usual means
were tried without effect; and on the evening of the
9th, Dr. Wistar was called, and with the aid of Dr.
Physick, proceeded to the operation late at night.
The protruding bowel, together with a portion of
omentum, were found in a state of sphacelation. The
stricture was divided. Two orifices were formed in the
intestine, through the upper of which a flexible tube
was passed, and several injections administered, but
with little effect; for although the patient passed a
small portion of feces from the artificial orifice and the
rectum, yet the vomiting still continued.
The patient slept about an hour after the operation,
and passed the next day without appearing to suffer
much. About 9 o'clock in the evening he became rest-
less, and vomited several times, complained of violent
pain, which commenced about the umbilicus, and ex-
tended across towards the right hypochondriac region.
Warm fomentations were applied to the abdomen, and
he took warm mint-tea, by which the pain and vomit-
ing were relieved. Two injections were thrown into
the artificial anus, a poultice was applied to the wound,
and the patient was left under my care for the night.
WITHIN THE ABDOMEN. 199
He was exceedingly restless through the night, and
vomited stercoraceous matter very copiously. Opium
was exhibited, both in the liquid and solid form, but was
immediately rejected by the stomach. He dozed at
short intervals, but had no refreshing sleep; the extre-
mities were cold, and his strength nearly exhausted;
warm bricks were applied to the feet. In the morning
he was slightly relieved; took, in the course of the day
and the next night, wine-whey, wine, &c. On the after-
noon of the 13th he became delirious, his countenance
exhibited marks of extreme prostration, and about five
o'clock on the morning of the 14th, he died.
Dissection.
Having obtained permission to open the body, (Dr.
Wistar being absent,) I proceeded to the examination
under the direction of Drs. Physick, Griffitts, and
Currie. Upon opening the abdomen, the small intestines
were found amazingly distended with flatus and feces;
the omentum was remarkably free from adipose sub-
stance, and was closely adhering to the intestines in
the vicinity of the stricture. The ends of the protruded
portion of bowel were firmly agglutinated to the exter-
nal wound, and the intestines above the stricture were
adherent to each other, and in a state nearly approach-
ing to mortification. The part which had been strangu-
lated, was a portion of the ileum, which commenced
about twenty-seven inches from its termination in the
ccecum. The intestine leading from the stricture toward
the duodenum was very much distended, except a por-
tion which was attached to the ring, and extended in an
obhquc direction across the pelvis, presenting an ap-
200 . STRANGULATION
pearance, which was aptly compared by Dr. Physick,
to one of the ureters entering the bladder.
This portion being fixed to the strictured part, was
pressed upon by the mass of distended bowel from
above, while on its lower surface it was antagonized
by the large muscles lining the pelvis, and thus its sides
were firmly pressed together, and the calibre of the in-
testine obliterated, for the distance of several inches.
The bowels above being distended beyond the point of
reaction, the obstruction was maintained, and must
have continued until some means could have been
adopted to induce peristaltic action, and thus cause an
expulsion of their contents.
The colon and rectum were empty, and very much
contracted; the stomach contained a large portion of
fluid, and dark stercoraceous matter.
Remarks.
In looking over this case which occurred many years
ago, some views, suggested by subsequent experience,
may be worthy of consideration in this place.
That the intestines may be so distended with flatus
as to suspend peristaltic action, is proved by ample ex-
perience. Thus in the latter stage of some of our fevers
the tympanitic abdomen occurs, as one of the most
alarming symptoms. I have known this state of things
to occur during the existence of a diarrhoea, and have
observed that the bowels were not only incapable of
discharging flatus, but that the diarrhcea was entirely
suspended.
In some violent cases of colic, accompanied with con-
stipation and great distension of the bowels, it is well
known that active medicines administered by the mouth.
WITHIN THE ABDOMEN. 201
and enemata thrown into the rectum, sometimes fail in
producing the desired effect, and rehef is finally ob-
tained by the introduction of a flexible tube into the
colon, through which flatus is extracted by an exhaust-
ing syringe.
A remarkable instance of this kind occurred to me
several years ago. I was called in consultation with a
young practitioner, in a case of extreme danger, at-
tended with obstinate constipation and enormous dis-
tension of the belly. A variety of medicines had been
tried without any beneficial effect. I explained the
views here presented, to the physician in attendance;
he most industriously employed the means suggested,
and while engaged in the operation with the tube and
syringe, the bowels began to act for themselves, and
flatus and feces were expelled in abundance, to the
great relief of the patient, who finally recovered.
26
CHAPTER X.
ANOMALOUS CASES.
The following cases do not fall under any of the
general heads of the subject of hernia, but as they are
not without some interest, I have placed them together
in this chapter, which may be considered as a kind of
appendix to those already given.
CASE XXXIX.
Hernia — Sudden Death from Strangulation,
2d mo., 1 822. Anthony, an old Italian sailor at the
Hospital, who was just recovering from a severe con-
tusion of the spine, was attacked with strangulated her-
nia. I was passing through the ward about half an hour
after it occurred, and was told by one of the patients
that Anthony had the colic. I inquired if he had rup-
ture, and ascertained the fact. It was an enormously
large hernia, and from that circumstance I expected it
would be more readily reduced. I directed the house-
surgeon to try some of the milder plans of reduction,
as the old man was feeble; and intended next day, if
he was not relieved, to have a consultation; but to my
surprise, on visiting the house next morning, I was in-
ANOMALOUS CASES. 203
formed that poor old Anthony died at about G o'clock,
A. M. The time that elapsed between the attack and
the death of the patient was about twelve hours: a very
uncommon result, especially in large ruptures.
The treatment that had been employed for the pur-
pose of effecting the reduction, was one moderate bleed-
ing, small doses of jalap and cream of tartar, and the
taxis.
No post mortem examination was permitted by his
friends.
CASE XL.
Entero-Epiplocele — Gradual approach of Strangulation^
Double Sac — Death.
10th mo. 19th, 1818. An old soldier was admitted into
the Almshouse hospital last evening. I saw him this
morning, and received the following account.
He had been afflicted with hernia since the year 1793,
when he was a soldier in St. Clair's defeat by the In-
dians. One of the red warriors threw his tomahawk at
our retreating patient, the head of which struck him
violently in the lower part of the belly, and caused a
rupture.
He has been able to reduce the contents of the sac
until within the last three years, since which a portion
has been irreducible. A few days since, while at Flat-
bush, on Long Island, he fell from a barn; the hernia
immediately increased in size, and he w-as unable to
put it back. He then went to New York, and from
204 ANOMALOUS CASES.
thence walked to Philadelphia. He had been in the city
one or two days before his admission into the Alms-
house on the 19th. In the evening, one of the house
pupils discovered that the hernia was strangulated. His
bowels were constipated, and he had vomiting.
In the morning I was sent for, and Dr. Hewson saw
him in consultation. The tumour was large, and evi-
dently contained fluid, it was tender to the touch, and
the skin covering it was somewhat discoloured. The
abdomen was tender on pressure, but not tumid. The
pulse and symptoms generally, did not indicate a state
of great danger.
We directed enemata of a strong decoction of senna-
leaves, and advised that the patient should be placed
in a warm bath, and while in the bath should try the
taxis himself.
It was concluded to meet at 3 o'clock in the after-
noon. But just before this time, the patient unexpect-
edly expired. He had been in the warm bath for about
fifteen minutes, and attempted reduction by the taxis.
He complained of feeling sick in the bath, and was re-
moved to his bed, and about an hour after he died.
Dissection,
/•
The hernial sac was unusually large, and contained
ten or twelves inches of the small intestine, with a
great part of the omentum. The bowel was in a state of
complete gangrene; the omentum appeared sound, ex-
cept a small portion which was in contact with the
bowel. The lower portion of the omentum was changed
in structure, as if it had been long excluded from the
abdomen. The hernial sac was very much contracted
at its lower portion. In the centre of the contracted
ANOMALOUS CASES. 205
portion there was a round aperture about the size of a
dollar. This contraction presented the appearance of
two sacs communicating by an orifice. The lower sac
contained that part of the omentum which was hard,
and had been irreducible. The large mass which had
recently descended, was contained in the upper por-
tion. Marks of extensive peritoneal inflammation were
observed in the abdomen, and adhesions were formed
amongst the intestines. Owing to the strangulation of
so large a portion of omentum, the arch of the colon
was drawn towards the abdominal ring, and the sto-
mach was displaced from its natural position.
CASE XLI.
^ Hernia — Semi-Strangulation,
12ih mo. 2d, 1820. I was called this morning to see
J. P., a black man, at the Philadelphia Almshouse. He
was labouring under a hernia. The descent of the
parts had taken place two days before.
The tumour was large and tender; the abdomen
rather tense; the tongue furred; the pulse not much
excited; and there was no vomiting.
I ordered the patient to be placed in a warm bath,
and directed castor oil, of which he took two ounces.
He had previously had an enema, which had operated
twice. In the afternoon, as the oil had not produced its
effect, ordered jalap gr. x. with crem. tart. 9i. to be
taken every hour. At 9 o'clock in the evening, the or-
derly man reported that the patient had had two free
206 ANOMALOUS CASES.
stools. The hernia was still down; the abdomen tense,
and tender on pressure; the tongue much furred. The
symptoms were so threatening, that my colleagues in
consultation entertained serious views of the propriety
of an operation. I rested my opinion in favor of delay,
upon the fact of the patient having had free stools; for,
indeed, what more could an operation effect than this?
It was agreed to watch the case, and consult again if
necessary; and the jalap and cream of tartar were con-
tinued.
3d. Morning. The patient was freely purged by the
medicine. The hernia was still down, but the abdomen
had lost its tension, and was now flaccid. In the evening
I returned the protruded parts into the cavity of the
abdomen very easily, and applied a truss.
4th. I found my patient well.
CASE XLII.
Mortified Spot producing death — Hydatid in the Sac.
On the morning of the 21st of 8th mo. 180G, I visited
E. F., a delicate woman aged about forty-five years,
residing in La3titia court. She stated that she had been
subject to hernial descents for the last two years, but
had always succeeded in returning the bowel without
medical aid.
The present attack commenced on the night of the
17th instant. She had a discharge from the bowels im-
mediately after strangulation, but none since. The only
medicine she had taken was a dose of salts, and herb
ANOMALOUS CASES. 207
teas prepared by her neighbours. The tumour was tense *
and painful to the touch; the tongue was furred; and
the pulse moderately tense. I bled her about oxii.; she
complained of being sick. I then attempted the reduc-
tion by taxis, but failed. I directed ice to be applied to
the tumour, a purgative enema, and small doses of
jalap and cream of tartar, with oil of cinnamon every
two hours. I visited her again in about four hours.
The tumour was more flaccid. I again tried the taxis
without effect. The powders had been rejected by the
stomach. I directed the warm bath, and a continuation
of ice to the tumour.
I again visited her in about four hours. Her appear-
ance was now more alarming. The pulse was sinking,
the vomiting continued, and the hernia remained irre-
ducible. A consultation was called of Drs. Griffitts,
Hewson and Dorsey, who met me in a short time. But
the change was so great that it was thought most pru-
dent not to attempt the operation.
In a few hours after she died.
Dissection.
On dissecting off" the integuments, the tumour pre-
sented a purplish appearance. On opening the sac, a
quantity of bloody serum escaped. A very small portion
of small intestine was involved in the stricture, which
was in a gangrenous state. Appended to this was a
hydatid of considerahle size. The intestines above the
strictured part were distended with flatus. The appear-
ances of inflammation within the cavity of the abdomen
were very slight.
CONCLUSION.
From the preceding? views, predicated on a variety
of cases narrated in this work, the author has deemed
it expedient to submit, in the form of corollaries, a
series of practical precepts, which may, perhaps, prove
important as a guide to the young practitioner.
In every case of colic, always suspect strangulated
hernia.
Be not deceived by a free operation from the bowels;
for it generally takes place directly after the occurrence
of strangulation.
The symptoms of strangulation are sometimes more
violent and dangerous in a small than a large hernia.
Guard most carefully against the employment of force
in the taxis. Long-continued and injudicious efforts to
procure the reduction of a strangulated bowel by taxis,
must greatly increase the danger of the patient. The
experience of Dessault on this subject is worthy of con-
stant remembrance — " You may always hope for suc-
cess in a hernia which has not been touched before
operating." A patient who has long been accustomed
to put up his own rupture, will generally perform the
taxis much better and more safely for himself, than any
surgeon can do it for him. Let not professional pride
interfere with the dictates of common sense, and the
voice of humanity.
In old, or delicate and feeble subjects, have a care
about using violent remedies to reduce the strangulated
COROLLARIES. 209
parts, especially a short time before the operation.
They may exhaust the vital energies. The lancet may
be carried too far. In some subjects the tobacco injec-
tion is far more to be dreaded, than the operation when
properly performed.
Cases of concealed hernia call for the most accurate
examination of the parts. The stricture may exist at
the internal ring, and may readily elude a superficial in-
spection.
When the symptoms are urgent, " delays are dan-
gerous."
Remember the expressions of the experienced and
judicious W. Hey, of Leeds: " I have often had
occasion to regret that I performed the operation too
late, but never that I performed it too early."
Give a full, clear, and candid statement of the case
to the patient and his friends before the operation.
Carefully avoid technicalities. Clothe ideas in language
that a very plain capacity can comprehend.
Shave the parts before the operation.
In making the first incision through the skin over the
tumour, let it be well pinched up as directed in the ope-
ration. Use a sharp-pointed bistoury with its back to-
wards the hernial tumour. .
Secure all blood-vessels that may be of sufficient size
to obscure a delicate dissection by an eflfusion of blood.
Be not alarmed about complicated layers of fasciae;
they may be cautiously, but very safely divided, con-
formably to directions in the chapter on the operation.
Always open the hernial sac.
Difficulties may arise from the absence of fluid, and
from adhesions, but these may be safely overcome.
In entero-epiplocele, there may be a sac within a sac.
27
210 COROLLARIES.
The intestine may be entirely obscured from view by
the omentum, which covers it hke the crown of an arch.
This must be opened before the real seat of stricture
can be ascertained.
Be not alarmed at the bloody fluid which may escape
from the hernial sac.
•Examine if the smell be cadaverous.
After the sac is so far opened as to admit the index
finger, always bear in mind that this is the best director.
In inguinal hernia divide the stricture upward.
In femoral hernia do the same.
Should the obturator artery present in front of the
stricture, the utmost caution must be observed.
I would recommend for the division of the stricture,
the curved and blunt-pointed bistoury guarded as di-
rected, and would prefer a dull rather than a sharp
instrument. Let the stricture be gently divided by "?iz6-
5/m^," rather than sharp cutting.
A very slight division is generally sufficient to admit
the finger by the side of the bowel into the cavity of the
abdomen.
Should a thick coat of lymph be eflfused over the
strangulated parts, remove it gently with the JIat handle
of the scalpel and the fingers.
Be exceedingly tender in the separation of adhesions.
Remember that the signs of mortification as set down
in books are very uncertain. The usual symptoms may
appear when the bowel is not mortified. They may be
absent at the very moment when the bowel is mortified.
Let not a dark purple colour of the bowel or even
an absence of circulation, decide the question of its ac-
tual death.
Most scrupulously refrain from making an incision
into the bowel on incomplete evidence.
COROLLARIES. 211
When the bowel or the omentum arc found in a state
of mortification, do not Hghtly esteem the efforts of
•nature, but rather be cautious about the interference of
art. The former is intuitive, capable of eluding many
difficulties, and under very discouraging circumstances,
it may produce the most happy results. The latter,
aided by the lights of experience, and accompar.ied
with sound discretion, may also accomplish much, at the
proper time. While in some instances, well intended,
yet officious interference with the vis medicatrix na-
turae, may prove to be zeal without knowledge, which
is said to be like courage in a blind horse.
Be especially careful to avoid the return of expatri-
ated omentum into the abdominal cavity, for reasons
already assigned.
To cut off a large portion of omentum near its root,
and then to return it to its natural situation, subjects
the patient to the hazard of dangerous hemorrhage,
unless the bleeding vessels be secured by ligatures.
To apply ligatures to the omentum, and then permit
it to recede into the abdomen, carrying the ligatures
with it, is to adopt a very dangerous practice. It is
calculated to maintain the imperfection of a most im-
portant cavity, and to induce peritoneal inflammation.
If a necessity should arise during an operation for
hernia, to delay procedure for a short time, cover the
wound with a bladder partly filled with warm water.
It can be retained in its position by the hand of an
assistant.
Permit not a dread of the infammatory effects of opium
improperly to discourage its use in strangulated her-
nia. It may be justly regarded as a most valuable arti-
cle in the treatment for reduction, and also before and
212 COROLLARIES.
after the operation. When an anodyne enema is used,
remember it is more powerful than is generally sup-
posed. I consider sixty drops of laudanum by the rect
tum, quite equal to thirty by the mouth.
The operation for umbilical rupture in infants, as
recommended by Dessault, is believed to be unneces-
sary. Nature is generally able to effect the cure without
any other assistance from art than adhesive strips, and
a bandage; or even without such aid.
When called out into the country, always carry
along a few spermaceti or wax candles. On this point
I speak from experience. Any surgeon who has per-
formed a delicate operation in the dead of the night, in
some of our farm houses by the light of " home-made^''
candles, will Understand my meaning.
After the operation, gentle laxatives should be used
instead of drastic purges. Castor oil is peculiarly well
adapted, or a solution of manna and cream of tartar.
Should the symptoms of strangulation continue Un-
relieved, the steady use of extremely minute portions of
calomel, as shown in several cases that are narrated,
may produce a most salutary effect.
The diet should be carefully regulated until the im-
mediate danger has ceased. Hard and indigestible ali-
ment is obviously improper. Liquid and soft diet, adapt-
ed to the stomach of the patient, is important, such as
oatmeal gruel, sago, Indian or rye mush, &c.; the latter
is gently aperient, especially if eaten with molasses.
In giving the preceding corollaries at the close of
the essay on hernia, it is hoped that the author has not
COROLLARIES. 213
exposed himself to the charge of tautology. There are
few subjects in surgery that require a more thorough
and exact knowledge of all the various and probable
difficulties that may arise during an operation, than
strangulated hernia. The surgeon should be prepared
calmly to meet, and promptly to overcome them. When
he has a living man lying before him on the operating ta-
ble, and has proceeded so far as to have his bowels in his
hand, he will then most assuriedly understand the ne-
cessity of having al in his own lamp. It would be an
unpropitious moment to abandon his patient, until he
could turn over the pages of a book to study out the
course to be pursued. He will then not only see but im-
pressively yee/ the importance of carrying a book in his
own head, in order to direct the movements of his hand.
PART II.
DISEASES OF THE URINARY ORGANS.
CHAPTER I.
RETENTION OF URINE.
There is a marked distinction between retention and
suppression of urine. The latter implies a want of
power in the kidneys to secrete urine. This is well
understood by medical men accustomed to attend yel-
low fever patients; and it is generally a mortal symp-
tom. During my residence in the Yellow Fever Hos-
pital, when a young man, an opportunity was given of
observing the condition of the bladder in this disease,
and of confirming it, after death, by dissection.
In retention, the kidneys secrete urine, which is carried
by the ureters into the bladder, but, from causes here-
after to be developed, it cannot be discharged. As it
accumulates, the viscus becomes distended, and it is
not uncommon for the bladder to rise a considerable
distance above the pubis, so as to be distinctly felt by
laying the hand upon the abdomen. The introduction
of the fincrer into the rectum, also enables the surireon
to ascertain the distension of the bladder.
Patients affected with sudden retention of urine suffer
extreme pain — making violent and ineffectual attempts
to discharije the contents of the bladder. Seldom do
we meet with any description of persons who have
stronger claims upon our active sympathy, and whose
intense distress appeals more forcibly to the humanity
of the surgeon.
28
218 RETENTION OF URINE.
I shall not attempt to enumerate all the causes of
retention of urine. An extended investigation of cases
in books, both ancient and modern, will supply a variety
which may be proper for a work purely systematical;
here it is rather my object to detail the results of my
own observations. Among the more common causes,
particularly in old people liable to the disease, damp
and cold feet may be mentioned. Long-continued and
severe exposure to cold may excite a spasm and rigidity
in the urinary organs, causing retention and severe
pain. Stricture of the urethra, accidents involving
fractures of the pelvis, contusions and lacerations of
the abdomen and perineum, and an enlarged and tumid
state of the prostate gland, will be found among the
causes of retention discussed in the following pages.
SECTION I.
DECEPTIVE SYMPTOMS.
Before entering upon the recital of particular cases
illustrating the causes which have been enumerated, it
will be proper to notice the subject of deceptive symp-
toms in retention of urine. Unless the practitioner is
thoroughly acquainted with this part of the subject, he
may be completely deceived. His sagacity and skill
may be called in question, and the suffering and even
danger of his patient may be greatly increased, by the
improper delay of efficient treatment.
After the bladder has reached a certain point of dis-
DECEPTIVE SYMPTOMS. 219
tension, a copious flow of urine frequently occurs. This
may induce the medical attendant to believe that the
obstruction has been overcome, and that the disease
has terminated happily. The experienced surgeon, how-
ever, is always on the alert: he ascertains that the flow
of urine is involuntary ; he places his hand over the pubic
region, and feels the distended bladder, which is pain-
ful on pressure; he soon discovers that the patient is
not relieved. Under these circumstances a fatal termi-
nation of the case may be expected, unless prompt and
judicious practice be adopted.
Another condition of the bladder may occur, still
more deceptive than the preceding; and it may elude
the vigilance even of a watchful sentinel. The bladder
may discharge a portion of the urine under the influ-
ence of the will, and may still continue to retain a part
until it becomes largely distended. It may be thus gra-
dually and habitually inducted into a state of insensi-
bility, which will admit of very unnatural distension.
All this may take place without the intense suffering
and immediate danger which accompanies the disease
when it occurs suddenlv. Instances of this kind exist-
ing among patients affected with chronic disease about
the neck of the bladder, particularly the prostate gland,
are well known to surgeons.
My preceptor, the late venerated Dr.Wistar, used to
relate a case of this kind. A respectable old citizen, a
judge in one of our courts, was labouring under dis-
ease of the prostate gland. On one occasion, while the
Doctor was in attendance, he made regular and minute
inquiries of his patient, in regard to the discharge of
his urine. During an attendance of many days, he was
informed by the patient that he discharged his urine at
220 DECEPTIVE SYMPTOBIS.
pleasure; but certain symptoms induced the Doctor to
examine for himself, when, to his surprise, he found
that the bladder had risen considerably above the pubis.
He at once introduced a catheter, and drew off nearly
two quarts of urine.
This deception may exist even in cases of an acute
and recent character: the bladder may evacuate a
part of its contents under the influence of the will, and
yet may retain enough to cause an enormous and fatal
distension of this viscus. This I have seen, not only in
adults, but also in a tender infant — not in the tenth
year, or tenth month, but on the tenth day of its life.
Cases of this will appear in their proper place: that of
the infant has been published by Dr. Dewees, and has
been disputed in a foreign journal; but, as the surgeon
who introduced the catheter, I do positively attest the
fact. The urine was put into a bottle, corked and sealed,
then weighed, and it is now in my possession. I fully
admit that the case is of a most uncommon character;
but where the narrators are known, it will be ac-
credited.
CASE I.
Enormous distension of the Bladder — Uri7ie discharged
under the injluence of the will — Death.
Columbia, on the banks of the Susquehanna, Lan-
caster county, Pennsylvania, 6th mo. 26th, 1812. Being
on a visit to my relatives in this place, I was requested
by Dr. H. M'Corklc, a practitioner in the town, to visit
de;ceptive symptoms. 221
with him, a female patient, whom he had been attend-
ing for several weeks, with a low nervous fever.
Dr. Thomas Griffith, of the same place, had visited
her with him several times, in consultation. About ten
days previously to my seeing the patient, Dr.' M'C. had
perceived a tumour in the abdomen, which had not
risen far above the pubis; but had been steadily increas-
ing, accompanied with considerable tenderness of the
abdomen on pressure. As the case was obscure to the
physicians in attendance, my opinion was requested.
The patient was a young married woman, delicate
in her frame, and the mother of three children. Her
skin was cool; pulse very frequent and feeble; tongue
moist, moderately furred, and of a light-brown colour
in the middle. She was in a very exhausted state. On
examining the abdomen, one might readily have sup-
posed, from the size of the tumour, that the patient was
almost in the last stage of utero gestation. I could dis-
tinctly perceive the fluctuation of a fluid, and should
have supposed the case to be ascites; but on carefully
passing my hand over the abdomen, I clearly dis-
covered a circumscribed tumour. Between the superior
part of the tumour, and the termination of the xiphoid
cartilage, there was a small space, -which retained its
natural appearance, which could not have been the
case, had the swelling arisen from a general effusion of
fluid within the abdominal cavity. As the tumour occu-
pied the anterior and central part of the abdomen, it
was not likely to be ovarian dropsy, nor would the his-
tory of the case justify such a conclusion.
My attention was now directed to the bladder. On
inquiry, I was assured that the patient passed urine in
considerable quantities^ and under the injluence of the will.
222 DECEPTIVE SYMPTOMS.
But knovviniij that this mi^ht occur while the bladder is
suffering from great distension, I advised the introduc-
tion of the catheter. We gave her a few drops of lau-
danum, and at the request of the attending physician,
I introduced the instrument without the slightest diffi-
culty. Very high-coloured urine began to flow through
the catheter, and as it flowed the tumefaction of the
abdomen gradually lessened. After about two quarts
had passed off", a paroxysm of extreme restlessness
occurred. The patient insisted on rising from bed, and
no persuasions could induce her to remain quiet. I was
under the necessity of withdrawing the catheter. Her
exertions evidently exhausted her. She sat upon the
close stool, and had a slight discharge from the bowels.
The pulse sank; cordials were exhibited; but all eflbrts
to arouse the system failed, and in a few minutes she
expired.
In order to guard against debility, arising from a
removal of distension, a broad bandage was passed
around the abdomen, as in tapping for dropsy, before
she was permitted to sit erect. I think it probable that
several quarts of urine remained in the bladder. Per-
mission was asked to open the body, but was not
obtained.
CASE II.
Retention in an Infmit — Bladder greatly distended —
Death.
6th mo. 25th, 1822. I was called by Dr. W. P. De-
wees, to visit a female infant of G. D. B., on the tenth
DECEPTIVE SYMPTOMS. 223
day after its birth. The history of the case is as fol-
lows:
At birth the child was firm and plump, and continued
healthy for several days. It passed urine freely. On
the night of the 20th it was very uneasy; the next day
it cried very much, and appeared to be in great pain,
which came on in paroxysms. It passed no urine. The
parents remarked, that the infant had evidently shrunk,
and was now smaller than at birth. It continued in this
state until the morning of the 25th, the child getting
worse, and being at times in great agony. The stools
were as green as the expressed juice of rue.
When I saw the patient, the belly was enormously
distended, and the veins on the surface were greatly
enlarged. Dr. Dewees had left a note, stating the case,
and requesting me to be provided with a small catheter,
as he was under the impression that the bladder was
distended. I introduced a very small flexible gum cathe-
ter into the bladder; no urine follow ed, and I was really
inclined to the opinion that the distension arose from
some other cause; but Dr. D. being convinced that the
tumour arose from distended bladder, I withdrew the
tube, and on carefully examining it, I found it was some-
what obstructed. As it w^as so very small, the slightest
impediment would prevent the passage of urine through
it. I had omitted to clear the tube, by passing the sti-
let through it, before its introduction, which ought
always to be done; from a neglect of it, I might have
left this patient under a false impression, if Dr. D. had
not expressed his opinion of the case so decidedly.
After passing the stilet through the catheter, it was
introduced a second time, and the urine then floAved in
a very small stream, and ample evidence was furnished
224 DECEPTIVE SYMPTOMS.
of the state of the bladder. As the discharge continued,
the tension of the abdomen diminished, and the child
actually fell asleep while the catheter was in the blad-
der. The bore of the instrument was so small, that
about three quarters of an hour elapsed before the con-
tents of the bladder were evacuated. At the close of
the operation the distension of the abdomen had entirely
subsided, and on measuring the quantity of urine which
had been drawn off from this tender infant, it actually
measured eighteen and a half ounces avoirdupois "weight.
26th. Drew^ away by the catheter several ounces of
urine in the morning, and again in the evening. The
mouth and tongue of the little patient are covered with
aphthous sores. The labia3 pudenda — which were pro-
tuberant, and much inflamed previous to the introduc-
tion of the catheter — have improved in appearance.
27th. The aphthous disease appeared to have extended
through the route of the ahmentary canal, and this day
the patient died.
CASE III.
Incontinence^ with Retention of Urine.
Girardwas admitted as a patient into the Penn-
sylvania Hospital sometime in the \2th rno. 1824, la-
bouring under an incontinence of urine of some months
standing. Two or three days after his admission, he drew
my attention to a swelling of his abdomen, which he
said had existed for some time. It presented very much
the appearance of the abdomen of a woman somewhat
DECEPTIVE SYMPTOMS. 225
advanced in pregnancy. A hard tumour extending
above the umbihcus, and having some little elasticity,
led to the introduction of a catheter, and at least three
quarts of urine were drawn off' by the instrument, to the
great relief of the patient. After this, the catheter was
introduced twice in every twenty-four hours, for a
length of time, and about half a gallon of urine was
evacuated at each operation. The patient finally reco-
vered.
CASE IV.
Retention fromExhaustion and Nervous Irritation — Urine
Discharged under Injiuence of the Will.
12th mo. 2d, 1830. G. M*C., a member of the le^is-
lature from the interior of the state, came to the city to
consult Dr. Physick and myself. He had been for a
long time subject to hemorrhoids, which had been
attended with profuse hemorrhage, by which he had
been nearly exhausted.
He was extremely pale, was affected with violent pal-
pitation of the heart; vertigo; hurried respiration after
the least exertion; throbbing of the temporal arteries;
frequent attacks of cough; nausea and vomiting; severe
erratic pains; oedematous limbs; and a sensation of
fulness in the cardiac region.
On the 3d, assisted by Dr. Physick, I passed two wire
ligatures around the hemorrhoidal tumours. On the
next day his exhaustion was extreme, accompanied w^ith
restlessness and delirium. While I was with him, he
29
226 DECEPTIVE SYMPTOMS.
passed, under the influence of the will, a considerable
quantity of pale urine; but as his restlessness was un-
abated, I was induced to suspect that the bladder
was not yet relieved. A close examination proved
that my suspicions were correct. I immediately intro-
duced a catheter, and drew oft' at least a quart of urine,
to the great relief of the patient. His restlessness and
delirium subsided, and he fell into a tranquil slumber.
CASE V.
Incontinence and Retention of Urine.
llth mo. 11th, 1834. 1 was consulted by J. H. C, a
respectable merchant, labouring under incontinence of
urine, attended with considerable pain. I had several
times prescribed for this individual, during the past year
or two, for symptoms denoting irritable bladder, of
which he had been relieved by diluent drinks, venesec-
tion, &c. I found he had been suffering for several
days from great difficulty in voiding his urine. He felt
an inclination to urinate every twenty or thirty minutes,
and passed but a small quantity at each attempt. He
was unable at this time, to pass his water, while stand-
ing, without having a discharge from his bowels. I
explained to him my views of his case, and advised him
to allow me to introduce a catheter; he was very anx-
ious, however, that some other means should be tried,
from a dread of the instrument and from a fear that his
accustomed occupation would be interrupted. I di-
rected him to be bled; to drink freely of flaxseed-tea;
RETENTION FROM COLD. 227
and to use anodynes. As he was very improperly serv-
ing on a jury in one of our courts, I did not see him
for several days. On being sent for again, I found the
irritation had increased so much, that on every attempt
to void urine he was threatened with a discharge from
the bowels. His appetite had failed; his pulse was quite
feeble; and he was somewhat emaciated. As he was
discharging his urine frequently at this time, he could
not suppose that his bladder was distended; but on in-
troducing the catheter, I drew off about half a gallon
of water, to his great surprise and relief.
The operation w^as repeated for several weeks, morn-
ing and evening, by myself or son. At each intro-
duction a large quantity was drawn off, although he
continued to discharge urine during the intervals. I
instructed him in the manner of introducing the in-
strument for himself, with which he soon became fami-
liar, and he then used it, generally three times every
day, drawing off in this manner, about three pints, and
discharging in the natural way about one pint.
He still continues this practice. His health is very
much improved, and he is able to attend to some busi-
ness.
SECTION II.
RETENTION FROM THE EFFECTS OF COLD.
Long continued, and also sudden exposure to cold,
may bring on severe spasmodic contraction of the
urethra, causing retention of urine, and much dis-
^28 RETENTION FROM COLD.
tress to the patient. These are instances in which sti-
mulants may sometimes be employed with advantage.
In illustration of this point, I will introduce the follow-
ing case.
CASE VI.
Retention from Cold.
Many years ago, one very cold night, I was called
from my bed by a watchman, who said he had with
him a man who could not pass his urine. As I resided
at no great distance from the watch-house, and was apt
to be called up by the city watch in cases of trouble
among their prisoners, I felt much inclined to remain
in a warm bed during such an inclement night. I advised
the officer to carry the man to the watch-house, and
keep him in a warm room; promising that I would call
in the morning, and have him conveyed to the Infirm-
ary. The poor suffering patient, however, felt himself a
party concerned in the case, he fixed himself down on
a bench at the door, and was determined to give a voice
on the occasion. He immediately commenced a howling
under the window very analagous to that of a large dog.
It was sufficient to disturb the neighbourhood. I was
compelled to appease him by an assurance that I would
come down and attend to his case. I soon had cause
to rejoice that I listened to his complaints. He entered
my house — he was completely chilled, his bare skin
visible through his tattered garments — his condition
was a fair example of human degradation and wretch-
edness.
RETENTION OF URINE IN FEVER. 229
I attempted to pass the catheter, but the urethra was
in such a state of spasmodic contraction, that it was
impossible. I procured for him some gin; the poor
wretch swallowed it with avidity; he took two glasses.
After warming him, I sent him to the Hospital, accom-
panied with a note to the house-surgeon, and then slept
myself more soundly than I should have done had I
turned a deaf ear to his cries. Next morning I found
all the difficulty was terminated. The spasm was re-
laxed and the urine passed freely. Here the gin was
useful; but very great caution is required in employing
such a remedy in ordinary cases.
SECTION III.
RETENTION OF URINE IN FEVER.
When we contemplate the varied conditions of the
system as displayed in the progress of febrile diseases —
when we discover the chain of healthy associations to
be broken, and a new order of morbid and irregular
actions to arise and gain the ascendancy, it ought not
to be a matter of surprise that the urinary organs should
participate in the general derangement. It is certainly
a source of regret that this simple foct is too often
overlooked by attending physicians — more especially
by those who are not familiar with surgical practice.
The condition of the bowels in cases of fever, is
deemed a most important subject of attention by every
judicious practitioner. The alvine discharges are in-
230 RETENTION OF
spected; inquiry as to the quantity, colour, and fre-
quency of stools; voluntary or involuntary; all these
follow as natural, every-day questions, in our attend-
ance on fever patients. Great irregularity in these re-
spects is often observed; and, especially when delirium
occurs, the most ample evidence is afforded that con-
stant attention on the part of the physician and nurse
is absolutely necessary.
Should these inquiries be neglected, the medical at-
tendant would probably soon make himself the subject
of severe and just criticism, by that important and use-
ful class of assistants in the chambers of the sick —
intelligent matrons and nurses.
Happy would it be for many a suffering patient, if
the morbid condition of the urinary organs were as
closely investigated by physicians and nurses, as the
disorders of the alimentary canal ! This declaration is
predicated, not upon the experience of a day, but its
truth has been established in my mind by many years
of observation. I offer it as a decided opinion, that
many a patient has suffered extremely in the progress
of fever, from this unsuspected cause. His primary
disease has been aggravated, and his danger increased
for want of a true understanding of his actual condi-
tion. The urinary bladder may be even fatally dis-
tended without a suspicion being excited as to the fact;
more especially if the patient be in a state of delirium.
Every experienced surgeon is famihar with this subject,
while with the mere physician it may pass without due
attention.
The following cases afford examples of this condi-
tion of the bladder in fever.
URINE IN FEVER. 231
CASE VII.
Retention in Fever.
I was called some years ago, in consultation with Drs.
Fairlamb and Coates, of Chester county, to visit a re-
spectable old miller, residing thirty-two miles from the
city. A letter from his attending physician was received,
stating that the patient had fever, and in the course of
his description of symptoms, he mentioned that there was
incontinence of urine. I at once anticipated the state of
the case, and according to my invariable custom, went
provided with catheters. On examining the patient my
suspicions were fully realized, the bladder was dis-
tended although urine flowed from the patient. I intro-
duced a catheter, and drew off the accumulated urine,
to the great relief of the old man, although he died some
time afterward with his primary disease.
CASE VIII.
Retention in Fever.
In the summer of 1819, M.P., one of my pupils, was the
subject of a dangerous and protracted fever of a remit-
tent form, accompanied with great nervous irritation,
without delirium. My departed friend Dr. Samuel P.
Griffitts, kindly aided me in consultation.
232 RETENTION OF
In the course of the fever, the bladder participated in
the derangement of the system, and he was unable to
expel its contents. I was under the necessity of intro-
ducing the catheter, through which the urine flowed
freely, to the great relief of the patient; the use of the
instrument was continued several times in twenty-four
hours, for at least ten days. He gradually recovered
from the fever, and acquired the natural power over
the bladder.
CASE IX.
Retention in Fever — Deceptive Symptoms.
In the year 1832, 1 was called in consultation with
my friend Dr. Otto, to see J. F., a young merchant.
He had been the subject of a severe fever for some
days, and was involved in great danger. At one period
he had delirium, was exceedingly restless, and distressed.
We suspected distension of the bladder, but on making
inquiry of the nurse, were assured that he passed his
urine, and if I recollect rightly, it was submitted in a
vessel for gur inspection; but such was the restlessness
of the patient, that an accurate examination was deter-
mined on in consultation.
The tumid state of the abdomen above the pubis,
accompanied with tenderness on pressure, left no doubt
on our minds as to the cause of these symptoms. A
catheter was introduced, and a considerable quantity
of urine was discharged. The operation was followed
URINE FROM CONTUSIONS. 233
by striking relief to the patient, and a mitigation of his
alarming symptoms.
From this period there was a gradual amendment;
but more than a week elapsed before the functions of
the bladder were so far restored as to dispense with the
use of the catheter.
SECTION IV.
RETENTION FROM CONTUSIONS OF THE BODY.
While I was surgeon to the Pennsylvania Hospital,
my services were frequently required for patients who
had received severe contusions of the abdomen. The
extensive brickyards, and gravel banks, in the imme-
diate vicinity of Philadelphia, form a fruitful source of
accidents of this description. I was early impressed
with the importance of watching the condition of the
bladder in these cases. My attention was particu-
larly directed to this subject, in consequence of a pa-
tient being brought into the institution who was caught
under a caving bank. On examination, we could dis-
cover no fracture of the pelvis, though the patient suf-
fered great pain, and was unable to pass his urine. The
catheter was introduced, and frequently repeated.
When reaction occurred, there was considerable fever,
and blood was abstracted. The patient finally reco-
vered.
This case induced the following reflections: If heavy
pressure upon the abdomen, suddenly induced; is suffi-
cient in some instances to fracture the bones of the
30
234 RETENTION FROM
pelvis, it is easy to conceive that the soft parts, espe-
cially the parietes of the abdomen, and even the vis-
cera including the bladder, may be, from the same
cause, involved in contusion, laceration, and their con-
sequences.
In this condition of the parts, it must be obvious that,
from the necessary contraction of the injured muscular
fibres, the natural efforts for the expulsion of urine
from the bladder cannot be made without greatly aug-
menting the distress of the patient. Hence it may
happen that either from inability on the part of the pa-
tient, or from the dread of extreme pain resulting from
the contraction of the abdominal muscles and the
bladder, the urine is permitted to accumulate, thereby
increasing the suffering and danger produced by the
original accident.
A considerable number of cases of this description
have fallen under my observation, and I am prepared to
lay it down as a settled principle, that in every instance
of severe contusion of the body, a steady watch should
be kept upon the bladder. If pain or difficulty attend
efforts to pass urine, the catheter should be invariably
employed. By this course the contused parts are kept at
rest, and the danger of inflammation and fever is di-
minished.
It may also be remarked, that the first effect pro-
duced by a severe contusion of the body, is to prostrate
the nervous system, and to induce severe pain. The
patient generally complains of chilliness, his skin is
cold, the pulse feeble, and the features contracted. In
this condition, the practitioner should endeavour to
allay pain by opiates, and wait for reaction of the sys-
tem before he attempts the abstraction of blood. This
CONTUSIONS OF THE BODY. 235
caution is rendered the more necessary, from the popu-
lar cry for bleeding, which always prevails, when severe
accidents of almost any kind occur.
When, in addition to the injury of the soft parts, the
bones of the pelvis are fractured, it is evident that the
contraction of the abdominal muscles, will cause a
movement of the fragments upon each other.
Under these circumstances, the call upon the surgeon
is still more imperative, to adopt, and rigidly to adhere
to the practice of absolute quiescence of the injured
parts until, aided by time and appropriate treatment,
nature shall accomplish a cure.
This class of accidents is sometimes farther com-
plicated by a rupture of the urethra.
To illustrate these latter conditions, the two follow-
ing cases are presented.
CASE X.
Fracture of tJie Pelvis and Ischuria.
6th mo. 2d, 1819. J. R., an Irish labourer, aged forty-
five years, was admitted into the Pennsylvania Hos-
pital, with a fracture of the pelvis and contusion of the
abdomen, caused by a loaded wagon passing over him.
He was a patient of the house, for some months dur-
ing last year, with chronic rheumatism. He was slightly
lame at the time of his discharge last autumn. On
the day of his admission, while attempting to cross the
street, in front of a loaded wagon, drawn by five horses,
he was knocked down by the leader, and the whole
236 RETENTION FROM
load, weighing three tons, passed over him. The wheels
of one side crossed the sacrum and ileum behind, as he
lay on his belly. He was bled immediately after the
accident, and then carried to the Flospital.
On examination, crepitus was discovered at the pos-
terior edge of the left os innomiiiatum, accompanied
with violent pain on both sides of the pelvis, about the
sacro-iliac symphysis. The patient was laid on his
back, and supported by pillows, &c. His pulse was
weak, and appeared for a few minutes to be rapidly
sinking. The extremities were cold, and the mind wan-
dering, with a slight degree of coma.
Tt. opii. gtt. XXV. were given him, and directed to be
repeated every six hours. No other injuries, except
bruises, were discovered in other parts of the body.
When any attempt to move him was made, he com-
plained of violent pain in the ascending ramus of the
pubis. Some urine was discharged under the influence
of the will, but the bladder could not be evacuated,
without the frequent use of the catheter. The patient
was kept perfectly quiet in a recumbent posture, until
the fracture united.
After remaining in the Hospital for a long time, he
was finally discharged. Dr. Reynell Coates, who was
at the time house-surgeon, informs me, that he saw this
man some years after he left the Hospital, and that he
had recovered sufficiently to move about, although he
was still lame.
CONTUSIONS OF THE BODY. 237
CASE XI.
Fractured Pelvis — Rupture of the Urethra — Muscular
Pouch 171 front of Bladder,
9th mo. 28th, 1818. H. O'C, a poor labouring man,
was brought into the Pennsylvania Hospital under the
following circumstances. He was engaged in digging
under a bank of earth near the Schuylkill. The bank
gave way above, and a large mass of earth fell upon
him. Some workmen in the neighbourhood came to his
assistance, dug him out, and he was conveyed to the
Hospital.
When I saw him, he complained of considerable pain,
principally in the abdomen, which was tumid, and ten-
der on pressure. His pulse was feeble, and his skin cool.
I directed mild nutritious drinks, with opiates to allay
pain, intending to wait for reaction of the system, be-
fore adopting a depletory course.
29th. The system had not reacted. The abdomen
was very much swollen, tense, and extremely tender to
the touch. As he had passed no urine since his admis-
sion. Dr. B. H. Coates, the house-surgeon, had very pro-
perly introduced a catheter, through which only a small
portion of bloody urine had escaped. In the evening
I again introduced the catheter; it passed under the
arch of the pubis, but a small portion of blood and
urine escaped as before. I was convinced that the in-
strument did not pass as far as it usually does, when it
enters the bladder, and was induced to believe from the
symptoms, that the viscus was ruptured. Several eva-
238 RETENTION FR03I CONTUSIONS.
cuations from the bowels were produced by castor oil,
given in small doses, and aided by an enema. But the
system never reacted.
I introduced the catheter twice after this, with the
same result. On the last introduction I was much sur-
prised to perceive bubbles of air passing out through
the instrument. The patient vomited frequently during
his short illness; and died about midnight on the 1st of
10th mo., being the fourth day after the accident.
Dissection,
10th mo. 2d. I was present this day, when Dr. B. H.
Coates examined the body.
The abdominal muscles below the umbilicus were
severely contused, being black with effused blood. On
opening the cavity of the abomen, the stomach and
intestines appeared healthy, but enormously distended
with flatus.
The left os pubis was fractured, and the fractured
portions separated from each other for some distance,
so that three fingers might be passed between the op-
posing surfaces. In consequence of the extent of this
fracture, the soft parts in the vicinity were very much
lacerated. The posterior portion of the urethra, under
the arch of the pubis, had been ruptured, and contained
an opening nearly large enough to admit the finger.
Through this aperture the urine had escaped, and mix-
ing with the efiused blood, had distended the lacerated
parts anterior to the bladder and peritoneum; forming
at this part a large pouch, like another bladder in front
of the true one. In consequence of its free passage in
this direction, the urine had not been infiltrated into the
cellular tissue, about the perineum and scrotum, as ex-
RUPTURE OP THE BLADDER FROM CONTUSION, &C. 239
tensively as it generally is in cases of ruptured ure-
thra. The muscular structure lining the pouch was of a
dark colour, resembling gangrene.
In this case, I believe the catheter never reached the
bladder, but passed through the aperture in the urethra,
and entered the pouch in front of that organ.
SECTION V.
RUPTURE OF THE BLADDER FROM CONTUSION OF THE ABDOMEN.
When the bladder is in a state of distension, the
application of external force may have the effect of
rupturing the organ. This is a very rare accident; one
case has fallen under my observation, which I will
briefly narrate.
CASE XII.
Rupture of the Bladder — Death.
A poor blind man was brought into the Almshouse
hospital, under the following circumstances:
He slept in the third story of a house, built for a
store, in which a door opened toward the yard below.
He rose in the night for the purpose of voiding his
urine, the bladder of course being distended. In at-
tempting to find the window, he fell against the door,
which opened, and he was precipitated into the yard.
240 RUPTURE OF THE BLADDER
He fell with the abdomen across a fence, and to use
his own simple language, " his belly struck first." He
was taken up, and was conveyed next morning to the
Almshouse.
I saw him soon after his admission. The abdomen
was tumid and tense, leading me, in the first instance,
to infer distension of the bladder. He had passed no
urine since the accident. On introducing a catheter, a
considerable quantity of blood mixed with urine, flowed
through the instrument. But the tension and uneasiness
increased; he complained of severe pain in the abdo-
men, and in about thirty hours after the injury, he died.
Dissection.
The fundus of the bladder was ruptured — urine had
escaped into the cavity of the abdomen, producing ex-
tensive peritoneal inflammation.
An account of a case of ruptured bladder, under
the care of my friend Dr. George Uhler of this city,
was drawn up by him, at my request, eighteen montHs
after its occurrence.
It exhibits a highly interesting example of lesion of
the bladder, from external violence, which resulted in a
complete solution of continuity in the injured part, and
an eflfusion of urine into the cavity of the peritoneum,
terminating in the death of the patient.
CASE xin.
Contusion of the Bladder — Lesion of the Fundus,
Dr. Uhler was called to the patient in the morning,
and received the following history of the case. On the
PROM CONTUSION OF THE ABDOMEN. 241
previous evening, the poor man had eaten very freely
of water-melon, after which he was romping near his
door with some of his young neighbours, when he acci-
dentally ran against a post, and received a severe blow
upon the lower part of his abdomen. The pain at the
moment was very considerable, but subsided in a short
time.
When Dr. Uhler saw the patient the next day, his
chief uneasiness was attributed to retention of urine, as
he had discharged no urine since the previous after-
noon. Tlie case did not appear very urgent, as the
patient was walking about his house, and the Doctor
merely advised him to take some diuretic medicine.
On visitino; him in the eveninsj the retention continued,
and the abdomen was much distended. The Doctor
now suspected the nature of the injury, introduced a
catheter, and drew off four and a half pints of urine of
a natural appearance. As the urine flowed, the tume-
faction of the abdomen diminished, and the patient
appeared to be entirely relieved by the operation. He
walked out to see a neighbour, and appeared free from
suffering or disease.
In a few hours afterward he was suddenly attacked
with symptoms of peritoneal inflammation, which con-
tinued for several days, when he died.
The body was examined by Dr. Uhler. An opening
lartre enou";h to admit three fiuijers was found in the
fundus of the bladder. The peritoneum exhibited evi-
dences of hiijh and general inflammation, from the
effusion of urine.
Remark,
Should a case of this kind fall under my observation,
I would introduce a small flexible catheter, and allow
31
242 RETENTION FROM CONTUSION OF THE
it to remain constantly in the bladder, in order to keep
the visciis entirely at rest, and to favour a contrac-
tion of its muscular fibres. By this means the sides of
the organ would be approximated, and the efforts of
nature to repair the injury would be promoted.
SECTION VI.
RETENTION OF URINE FROM CONTUSION OF THE PERINEUM
TAPPING THE BLADDER.
So far as my observation has extended, accidents of
this kind are very rare. When they do occur, they are
generally very serious in their character.
The direct application of force to the perineum is
followed by tumefaction of the parts, arising from the
effusion of blood, and subsequent inflammation. Such
a condition cannot take place without involving the
urethra in its consequences. The size of the canal is
frequently very much diminished, and great difficulty
is experienced by the patient in evacuating his urine.
So long, however, as he is capable of discharging urine,
even though the effort is attended with great pain, the
danger is comparatively slight.
When the obstruction becomes complete, his life is
put at hazard unless relief is obtained by proper means.
While the integrity of the urinal canal is maintained,
ultimate restoration, without the necessity of tapping
the bladder, may still be anticipated.
If the violence of the injury should have been suffi-
cient to lacerate the urethra, and the passage of a ca-
PERINEUM. TAPPING THE BLADDER. 243
tlieter into the bladder is impossible, the only alterna-
tive which is presented to the surgeon, is to form an
artificial outlet for the urine by an operation.
Two situations have been proposed by surgeons, for
the performance of this operation. Some recommend
that the puncture should be made through the rectum,
while others prefer the operation above the pubis.
I liave never seen the bladder tapped but once, and
then I was the operator. The case will be fully de-
tailed, in order to exhibit the difficulties of the opera-
tion by the rectum, at least in this class of accidents;
and to present the reasons why, with my present limited
experience, I should prefer the operation above the
pubis.
CASE XIV.
Contusion of the Perineum — Retention of Urine from
effusion of Lymph,
In the winter of 1820, a patient was admitted into
the surgical ward of the Almshouse Infirmary, under
the followinsf circumstances:
He had fallen into a tanner's vat, and had sustained
a severe contusion of the perineum and the parts adja-
cent. The scrotum and penis were much swollen. In
the latter there was great effiision, so as to cause a
very troublesome phymosis. I was obliged to treat this
by a number of small punctures with a keen lancet,
tln-ough which a serous fluid was discharged. The
patient passed his urine with very considerable diffi-
244 RETENTION FROM CONTUSION OF THE
culty. I placed him under an antiphlogistic plan of treat-
ment. Although the inflammatory symptoms subsided,
yet the stream of urine gradually diminished in size.
A small bougie or catheter could not be passed, and it
was with great difficulty the bladder could be relieved.
I supposed this to be the consequence of preceding in-
flammation, and that an eflfusion of lymph had dimi-
nished the diameter of the urethra. With a view to
promote the absorption of this lymph, I ordered the
camphorated mercurial ointment to be rubbed freely
and frequently on the perineum. This plan was per-
sisted in for some time, combined with the use of the
warm bath. The patient became worse and worse, until
at last his strongest efforts were insufficient to evacuate
the bladder, which became considerably distended. In
this dilemma I was afraid we should have to resort to
some serious operation. I endeavoured to introduce
a very small catheter without success. Having proved
in some instances the efficacy of large catheters after
failure with small ones, I introduced a flexible catheter
of very large size, with a stilet, and passed it down
to the obstruction, pressing it with moderate force
against the part. In a little while I felt something to
give way, or rather to tear. The catheter then ad-
vanced. Directly afterwards another obstruction was
encountered by the instrument, but it yielded more
readily than the first. Then, to my great joy, the ca-
theter entered the bladder, and the urine flowed freely.
In this case there was evidently an adhesion between
the sides of the urethra, producing an almost total ob-
literation of the canal. The large catheter, by distend-
ing the urethra, rent asunder the new-formed parts.
PERINEUM. TAPPING THE BLADDER. 245
One thing occurred in this case which was remark-
able. When the urine began to flow, instead of the ex-
quisite relief usually experienced by the use of the
catheter, the patient was seized with severe pain and
spasms, attended by strong retraction of testes. He
really seemed in an agony, and begged to have the
catheter withdrawn. He rose from his bed and requested
to be allowed to stand erect. I was obliged to give him
sixty drops of laudanum, but did not immediately with-
draw the catheter.
My last note of this case is dated several weeks
after the introduction of the catheter, and ends with
this information: — The patient is still in the hospital;
his condition much improved. I think he may soon be
discharged cured.
CASE XV.
Kctention of Urine from Contusion of the Perineum — Tap-
ping the Bladder.
lOth mo. 15th, 1828. Jeremiah Waterhousc, aged
about thirty-five years, farmer, a muscular, strong, and
admirably well-formed Englishman, was admitted into
the Pennsylvania Hospital with a severe injury of the
perineum and scrotum. The accident occurred in the fol-
lowing manner: — The patient Mas in the service of Geo.
Bleight, at his farm near Germantown. While in the
city with a farm wagon and horses, he was standing on
the shelvings of the wagon, when the horses started off-
he was thrown from his position and fell astride and in
246 RETENTION FROM CONTUSION OF THE
front of one of tlie wheels, which struck him witli great
force on the perineum. After the accident he was car-
ried home, and was visited by Dr. Betton, of German-
town, who advised his removal to the Hospital.
Dr. J. Rhea Barton, the attending surgeon at that
time being absent from the city, 1 w as called to visit
the patient, and saw him about twenty-four hours after
the injury was received.
I found him in great pain; his bladder was much dis-
tended, and he w^as entirely unable to pass urine. The
introduction of the catheter had been several times
attempted before I visited him by Dr. George Fox, the
house surgeon. He found it impossible to succeed.
The situation of the poor sufferer was sufficient to kin-
dle up the sympathy of any one that saw him. His
distress was intense, yet he bore it w ith manly fortitude.
I put forth my best endeavours to relieve him. Re-
peated attempts were made to introduce the catheter
with all possible gentleness. Every effort was unavail-
ing. I left him after directing that he should be freely
bled, and have leeches applied to the perineum, in order,
if possible, to reduce the inflammation and tumefaction
of the parts. An opiate was prescribed. On my return
again that night, the attempt to pass the catheter was
renewed, with the same result. At this visit my fears
were fully confirmed, that the urethra was extensively
lacerated. I ordered a consultation to be called next
morning, and left the patient, after directing that he
should be kept quiet by opiates.
My colleague. Dr. Thomas T. Hewson, met me at
10 o'clock. We found the patient in great pain, and
very anxious for relief. The catheter could not be in-
PERINEUM. TAPPING THE BLADDER. 247
troduced, and we concluded to tap the bladder from the
rectum.
When about to proceed to the operation, I intro-
duced my finger into the rectum, and was forcibly
struck with the absence of that elastic feeling imparted
to the finger in a common case of distended bladder.
Instead of this, it gave the sensation of a soft, doughy
substance, as if the indentation of the finger must have
remained sometime after it was withdrawn from the
part. I requested my friend Dr. Hew son to examine, and
his impressions were precisely the same. We concluded
that this state of things must be caused by an effusion
of blood between the rectum and bladder. We thought
it best to proceed with the curved trochar, as the au-
thority of surgeons, perhaps, preponderated in favour
of a puncture from the rectum in case of recent acci-
dent. I now introduced the instrument, and pushed it
through the rectum towards the bladder so far as ap-
peared necessary to reach the viscus. On withdrawing
the stilet, nothing but a little grumous blood passed
through the canula. We were placed in a painful di-
lemma. To fail in relieving a fellow creature from ex-
treme suffering was distressing, and we could not avoid
feeling increased interest in the patient, from the entire
confidence he reposed in us, and the readiness with
which he submitted to every thing we proposed.
It was now agreed to make a puncture a little higher
up, which was done, and the instrument was pushed as
far towards the bladder as we thought prudent. It re-
sulted in bitter disappointment; no urine passed through
it. Xo doubt now remained of a much more extensive
effusion of blood between the rectum and bladder than
we had anticii)ated. We met again at 3 o'clock, and
248 RETENTION FROM CONTUSION OF THE
Drs. Physick and Hartshorne, two of the former sur-
geons of the institution were invited, and kindly at-
tended. The whole case was laid fully before them;
they made one more unavailing effort to pass the ca-
theter, and we all united in judgment that the only
alternative which remained, was to tap the bladder
above the pubis. The patient was not only willing, but
desirous of having the operation performed.
Assisted by my friends Drs. Physick, Hewson, and
Hartshorne, and in the presence of a number of pupils,
I proceeded, and made an incision in the course of the
linea alba a little above the pubis, the parts being pre-
viously shaved. I carefully dissected down between the
pyramidal muscles, and soon felt the distended bladder.
I now passed a curved trochar down into the viscus.
The stilet was withdrawn, and the urine followed. I had
prepared for the occasion a second silver canula, with
a rounded point, and perforated with holes on the side
like the common catheter. This was accurately adapted
to the large canula, so that it could be passed through
it into the bladder. This was done, and the bladder was
relieved by a copious discharge of urine. The advan-
tage of this second canula consisted in its projecting
some distance beyond the other, and presenting to the
internal coat of the bladder, a smooth rounded surface,
instead of an abrupt edge. The canulae were now re-
tained in the bladder by means of tapes, and the wound
was closed by adhesive strips.
After the operation the patient was kept under the
use of opiates, and, for the first few days, upon a low
diet. He had but little fever, and passed his urine freely
through the canula; though with all the care that could
be taken, some portion would escape through the
TAPPING THE BLADDER. 249
wound by the side of the instrument. The afflictions of
the patient did not terminate here. His scrotum be-
came more tumid, and exhibited evident marks of gan-
grene. He was now placed on a very generous diet,
with bark, ehxir of vitriol, 6lc. Poultices were applied
to the mortified parts. Dr. Barton having returned, the
patient was placed under his care. A flexible catheter
was finally substituted for the silver canulse; the mor-
tified parts about the scrotum sloughed and healed;
but his constitution had received a shock too severe for
his ultimate restoration. As he weakened, a most ex-
tensive slough took place on his back, and he finally
died with hectic fever, 11 /A mo. 16th, about one month
after the accident. On dissection after death, it was
ascertained that the two punctures made through the
rectum had entirely healed.
The evidences presented on dissection in this case,
afforded to my mind the gratifying assurance, that the
poor sufferer did not sustain any material injury from
the unsuccessful efforts to puncture the bladder from
the rectum.
It has settled me, however, in the conclusion, that un-
til more enlarged opportunities for judging on this sub-
ject shall be afforded, I shall never again attempt to
tap the bladder from the rectum. The opinion of my
worthy old master, Dr.Wistar, was decidedly in favour
of the operation above the pubis; and it will require
some pretty clear evidence to change my present opi-
nion.
32
250 RETENTION FROM
SECTION VII.
RETENTION FROM DISEASED PROSTATE.
Among the diseases peculiar to advanced life, is an
enlarged condition of the prostate gland. This gland
is situated at the neck of the urinary bladder, and is
called into action in every effort to evacuate its con-
tents.
The morbid condition of this structure which we are
about to notice, first manifests itself by a frequent de-
sire to void urine, obliging the patient to rise several
times in the course of the night. This disposition slowly
increases, until the calls become very frequent, accom-
panied with severe pain and straining. As the disease
advances, retention of urine to a greater or less ex-
tent, not unfrequently takes place, requiring the use of
the catheter.
In some constitutions, the inroads of the disease are
gradual, and several years may elapse, without any
evidence of immediate danger, and the symptoms are
regarded rather as a source of inconvenience, than of
positive suffering. The aged subject may be kindly per-
mitted to pass out of life with some more acute disease,
thus escaping a protracted death from pain and con-
stitutional irritation.
When the complaint assumes its most aggravated
form, the sufferings of the patient become intense. The
bladder is excessively irritable, and incapable of retain-
ing even a small portion of urine, without producing
great distress. I have known a patient in this condi-
DISEASED PROSTATE. 251
tion to be compelled to rise tJiirly times in the course
of the night, making at each attempt strong efforts to
discharge a very small portion of urine.
As the disease advances, the energies of the system
are gradually exhausted. Emaciation, debility, hectic
fever, and death are the result.
A post mortem examination reveals the cause of the
symptoms just described. The prostate gland, which in
a natural state does not exceed the size of a horse-ches-
nut, may be found equal in bulk to a large pear. Some-
times the enlargement is most conspicuous in the late-
ral lobes, while in other instances the third lobe seems
to have been principally affected. The latter form is
the more serious, from the fact of this lobe forming, in
a natural state, a small projection towards the urethra,
which, when increased by disease, constitutes a large
triangular body, overhanging the opening of the ure-
thra into the bladder. This lobe acts the part of a
valve, which, under certain morbid conditions, may
completely close the opening from the bladder into the
urethra; offering a most serious mechanical impedi-
ment to the introduction of the catheter, which will be
noticed in its proper place. From the peculiar position
of the valve it must be evident, that in every effort to
expel the contents of the bladder, it is pressed more
firmly over the opening, and the obstruction is ren-
dered more complete. See PI. 1 and 2.
Another striking post mortem appearance, as ex-
hibited in the drawings, is the thickened and rough sur-
face of the inner coats of the bladder. The eye is ar-
rested w^ith a great number of strong bands of diflcrent
dimensions, and variously distributed, resembling very
closely the musculi pectinati of the heart. See PI. .3.
252 TREATMENT OF
These appearances are produced by an enlargement
of the muscular fibres of the bladder. It has been
supposed by some writers, that this condition of the
parts was produced by the chronic inflammation of
the mucous membrane, communicated to the muscular
coat. I am disposed to refer them to another cause.
I believe that this extraordinary development of mus-
cular fibre depends upon the frequent and violent con-
tractions of the organ, which are inseparable from this
distressing malady.
Its explanation may be referred to the same law
which regulates the size and development of muscles,
which are subjected to unusual exercise in other parts
of the body. Who has not admired, in passing along
our streets, the powerful flexors and extensors in the
arms of some of ourwoodsawyers,or the swelling deltoid
of the blacksmith accustomed to the daily use of the
sledgehammer. This same view might be extended to a
variety of muscles, more particularly connected with
various mechanical operations.
Between the bands formed by this thickened muscu-
lar fibre, it is not uncommon to observe pouches of
various dimensions, in which calculi are sometimes
deposited. As the bands enlarge, the stone is firmly
bound down, and may become completely encysted, thus
naturally causing a cessation of the symptoms.
SECTION VIII.
TREATMENT OF ENLARGED PROSTATE.
It would be a source of extreme gratification could
ENLARGED PROSTATE. 253
we offer the cheering prospect of radical cure, in this
distressing malady.
A great variety of remedies have been recommended;
but as far as my knowledge extends, they can rise no
higher in the scale than mere palliatives. To relieve
the violent pain attendant on the disease, we must
chiefly rely on opiates, particularly on anodyne injec-
tions. Emollient drinks, the warm bath, and sometimes,
under particular circumstances, general and topical
bleeding may be required.
The frequent use of the flexible gum elastic catheter
is generally demanded, and the patient should be in-
structed to introduce it for himself
I regard it as important in this disease, which, from
its intractable character, and the advanced age of the
patient, precludes the hope of a radical cure, that we
should adopt such palliative measures as will promote
the tone both of the body and mind. Hence moderate
exercise in the fresh air, and employment of the mind
on passing objects, is greatly to be preferred to con-
stant confinement within the narrow precints of a sick
chamber.
In the more advanced stages of the disease, when the
patient is necessarily confined to bed, the obstruction
may be so great as to render the passage of the cathe-
ter difficult. In these cases the constant wearing of the
instrument becomes necessary.
I have recently met with a suggestion in regard to
the treatment of enlarged prostate, emanating from a
source which entitles it to high respect. It is compre-
hended in the following extract from G. J. Guthrie on
Diseases of the Urinary Organs.
" A question has arisen in my mind, whether any
254 TREATMENT OP
operation could be done on the prostate from the peri-
neum; and I was led to entertain it, from finding, that
in a patient upon whom I had operated for stone, whose
prostate gland was much enlarged, I had rendered him
a further service in the diminution of the prostate; so
that instead of making his water with difficulty, he
afterwards made it easily, and the catheter passed with
facility, instead of meeting with a considerable obsta-
cle at the neck of the bladder. In fact, I was satisfied
I had cured, or nearly so, the disease of the left lobe of
the prostate, which I found to be much enlarged during
the operation."
To strengthen this suggestion, the author refers to
some observations of W. Blizard, read before the Me-
dico-Chirurgical Society, by which it appears that he
had several times divided the prostate when in an en-
larged condition, though not in a state of inflammation.
The condition referred to, is thus described in his own
language: " When the inflammation ceases, the puru-
lent matter may remain confined by the ^rm investmefit
of the prostate gland for a length of time, according to
various circumstances."
This condition does not present to my mind any
confirmation of the opinion of G. J-. Guthrie. In the
cases operated upon by Blizard, the inflammation had
ceased, and the object of the operation was to give
exit to confined pus. I have never seen such an
operation, and though I should be cautious about per-
forming it myself, I would not attempt to oppose
theoretical views to experience from such a source. I
have in my own practice, at this time, an elderly gen-
tleman, with diseased prostate, requiring the frequent
use of the catheter, and on two occasions nature ap-
pears to have relieved him, by the free discharge of
ENLARGED PROSTATE. 255
purulent matter from the penis, which I have supposed
camo from an abscess in the prostate gland. This dis-
charge, after continuing for some time, has on both
occasions abated, and finally ceased. The patient is
enabled to keep about, and uses moderate exertion in
business.
The proposition to lay open the prostate from the
perineum, in ordinary cases, demands serious consi-
deration. Should experience confirm the propriety of
this practice, it would open a cheering prospect to
many aged patients, who are doomed to pass their few
remaining days in suffering and sorrow. An enlarged
state of the prostate, instead of being a serious objec-
tion to the operation for lithotomy, w ould, under this
view, rather invite it, with a hope, that in addition to
the removal of calculus from the bladder, the prostate
might be radically cured.
I am free to confess with diffidence, that an incision
into a part enlarged by chronic inflammation, for the
purpose of radical cure, is not in accordance with my
views of sound surgical practice.
We must look to the experience of lithotomists,
either to sustain or reject this suggestion. In order to
be decisive, a post mortem examination should be made
in every instance, to ascertain whether the gland is
actually diminished in size. Removal of pain, and even
a restoration to tolerable health, after the operation for
stone, cannot be accepted as evidence of material di-
minution in the size of the prostate. The gland may
be increased in size without producing of itself much
suffering to the patient; while the additional irritation
of a calculus in the bladder may cause intense pain.
Under these circumstances, the removal of the calculus
256 TREATMENT OF
would render the patient comparatively very comfort-
able, without, at the same time, producing any other
effect upon the prostate, that to relieve it from the irri-
tation of a foreign substance situated in its immediate
vicinity.
Although my own experience does not furnish a case
of stone complicated with enlarged prostate, in which
an operation was performed, yet a striking instance
has lately occurred in this city, in the person of the late
Chief Justice Marshall. This highly distinguished and
excellent man, was subjected to the operation of litho-
tomy by Dr. Physick, and a large number of calculi
were removed from the bladder. The prostate gland
was considerably enlarged at the time of the operation,
and the third lobe was distinctly felt projecting into the
bladder.
The venerable patient recovered most happily, re-
sumed his official duties, and enjoyed a considerable
share of health for several years. He died with a dis-
ease unconnected with the urinary organs. A post
mortem examination was made, and the prostate parti-
cularly examined. Dr. Physick, (whose opinion on this
point was requested,) explicitly states, that the size of
the gland was not diminished by the operation. The
preparation is now in his possession.
Here we are presented with opposite experience, de-
rived in both instances from a very high source. The
proposition may, however, be still further examined.
Admitting that an incision into the prostate will pro-
duce a salutary effect, is it not possible, when this gland
becomes enlarged, that its firm investment by the mem-
brane mentioned by W. Blizard, may act on the same
principle as the thecae of the fingers in paronychia, or
ENLARGED PROSTATE. 257
the thick skin which covers the fingers of labouring
men in that disease. Where is the surgeon who has not
been called upon by hard-working men in extreme pain
in the early stage of felon, before the formation of pus?
He understands in a moment that the skin in these
cases, acts like a bandage drawn firmly over an in-
flamed part; and that the primary indication for relief,
as well as cure, consists in laying open the tumid finger,
and, by a free incision through the skin, thus removing
the stricture.
The effect of an artificial bandage on an inflamed
limb, is familiar to every experienced practitioner.
Who has not seen patients brought into a hospital ward,
a few days after receiving a fracture, with the limb
firmly bound by a roller. The patient suffering great
pain, and the parts rapidly verging on towards gan-
grene?
These illustrations include inflammation in an acute
form; but it is easy to apply the same reasoning to
morbid changes in structure, of a chronic character, and
thus " the firm investing membrane of the prostate
gland" may produce results somewhat analogous to the
thecae and thickened skin in paronychia. Hence it may
be supposed, that a division of the investing membrane
of the prostate may produce a salutary effect.
After reviewing the arojuments in favour and against
the suggestion of G. J. Guthrie, in the absence of suffi-
cient experience on the subject. I would modestly ven-
ture to say, that the division of the prostate would be
hazardous and improper. It must be recollected, that
this disease makes its appearance in individuals ad-
vanced in years, whose constitutional energies are
nearly exhausted, and that a severe operation of the
258 TREATMENT OF
kind proposed, might sink the system below the point
of reaction.
It may be remarked also, in connection with this
subject, that wounds of the prostate sometimes result
very inconveniently. Dr. Physick states a case, which
fell under his notice, of a man whose prostate had been
pierced by attempts to introduce the catheter, in un-
skilful hands. He recovered from the wound, regained
his health, and lived for several years; during the whole
of which time he was afflicted with incontinence of
urine.
One of the most important means of relief in this
distressing malady, consists in the dilatation of the
passage through the prostate gland. A plan of dilating
the urethra, by injecting fluid through a catheter, to the
extremity of which a thin bag is attached, was intro-
duced some years ago by Dr. Arnott, of London. It
was more particularly applied to the treatment of stric-
tures, though reference is made to its utility in cases
of enlarged prostate. — Treatise on Strictures of the
Urethra, pp. 163 and 178.
Dr. Physick has lately adopted a similar practice,
with the most gratifying success. He was consulted in
the case of an elderly gentleman of this city, who has
laboured for nine years under a disease of the prostate,
and has suflfered severely from occasional attacks of
retention of urine, requiring the use of the catheter.
On a late occasion. Dr. P. was called to him, suffering
under an unusually severe attack, the continuance and
severity of which had almost exhausted him. He pre-
pared a small flexible catheter, to the extremity of which
was attached a ])ortion of very thin bladder, firmly se-
cured by silk thread, which was covered with wax. The
ENLARGED PROSTATE. 259
instrument tlius prepared was introduced without much
dilhcuhy into the bladder. Warm water was then in-
jected through the catheter,and the bag thus distended.
An attempt was then made to withdraw the instrument.
As the distended bag entered the passage through the
prostate, considerable pain was produced; but it was
allowed to remain for some minutes in this situation,
and was finally brought through by gradual means.
Some blood flowed on withdrawing the instrument.
The operation afforded speedy relief, the health of the
patient rapidly improved, and he remained free from a
return of his symptoms for more than a year.
The result of this case is truly gratifying; in it we
perceive the skilful application of means in the hands
of one, who though advanced in life, is still active in
his efforts to relieve afflicted humanity.
I am now willing to suggest the result of my own re-
flections on this subject, after premising that they are
predicated on a case related to me by my beloved and
departed preceptor. Dr. Wistar. He tapped the dis-
tended bladder of an elderly gentleman above the pubis,
in consequence of his inability to introduce a catheter;
the difficulty being caused by an enlargement of the
prostate gland. In this instance the patient wore a gold
tube, in the opening made by the operation, through
which the urine was discharo[ed without difficulty.
From having been the subject of great sufTering for
years, he was by this means enabled to enjoy compa-
rative comfort; his health improved, and was so far
restored that he was in the practice of riding out to his
country seat, several miles from the city, not only in
his carriage, but sometimes on horseback. Nearly two
years elapsed under this favourable change. In the in-
260 TREATMENT OF
terim the diseased prostate had so far recovered, that
the patient could pass water through the urethra freely
and without pain. Thinking that the disease was cured,
he removed the tube, and relied entirely upon the natu-
ral passage. The consequence was, a renewal of the
disease in the prostate, of which he finally died. A
small fistulous opening continued above the pubis, but
the bladder never rose sufficiently high to admit of a
repetition of the tapping, and the tube could not be
replaced.
The striking relief experienced in this case, is evi-
dently to be referred to the removal of the sources of
irritation to which the diseased parts were subjected.
If a surgeon is called to a case of inflamed* knee-joint,
he orders the patient to bed, and fixes the limb in a
carved splint, thereby suspending all motion in the joint.
He reasonably calculates, that so long as the move-
ments of the part are permitted, inflammation and its
consequences may be expected.
The situation of the prostate gland is even worse
than that of an inflamed joint, because in the latter, the
patient may recline on his bed, and thus temporarily
suspend the motions of the part. But the silence of
midnight brings no settled repose to the patient with
enlarged prostate; his slumbers are short, and he is
frequently aroused to the renewal of painful efforts,
which are constantly aggravating his disease.
Now let us apply the same principles of treatment to
the enlarged and irritable prostate, and if figurative lan-
guage may be allowed, let it be placed in a splint, or in
other words let its functions be suspended. This may
be accomplished by tapping the bladder above the pu-
bis, and establishing another outlet for the urine.
ENLARGED PROSTATE. 261
Possessing as I do, but little confidence in the reme-
dial agents employed for the cure of enlarged pros-
tate, and viewing even palliative means, in some in-
stances uncertain, T have arrived at the conclusion,
that if, in the dispensations of Providence, I should
ever be subjected to this malady, I would certainly
avail myself as a last resort, of the operation of tap-
ping the bladder above the pubis. It would be far pre-
ferable for a man in advanced life, to be subjected to
the inconvenience of wearing a tube, through which his
urine could be discharged, than to be afflicted with a
painful malady, by which he would be led to a slow and
painful death.
The following cases are selected as illustrating the
manner in which the enlargement of the prostate gland
interferes with the discharge of urine.
CASE XVI.
NOTE.
The subject of the present note was a respectable
and wealthy merchant of Philadelphia, who, after ac-
quiring a handsome estate, retired from business, to
spend the remainder of his life surrounded by the com-
forts of a happy home; but he was assailed by a pain-
ful and protracted disease, which, after years of suffer-
262 TREATMENT OF
ing, closed his life. My excellent and departed friend,
Dr. Samuel P. Griffitts, was repeatedly associated with
me in consultation in the case.
I was called to visit him in the winter of 1809. I
was sent for in the night. He was labourinsf under vio-
lent pain, which was supposed to be colic, but an exa-
mination proved it to be situated in the urinary organs.
The patient suffered great distress, and was unable to
pass his urine. The catheter was introduced, and I
was obliged to repeat it two or three times a day dur-
ing the violence of the symptoms, and had to resort to
the usual treatment by the warm bath, opiates, &c.,
with moderate depletion. Under this course, his more
urgent symptoms abated, but the inability to pass the
urine without the aid of the catheter continued, and re-
quired my attention for a long time.
As the warm weather approached, he was desirous
of spending the summer at his country seat, about six
miles from the city. He had a very intelligent- coloured
lad who waited on him, and I taught this lad the use
of the catheter, so that he could introduce it very well.
When the patient returned to the city in the autumn,
my attendance on him was resumed. He still required
the use of the catheter, although his condition was
much improved, and he enjoyed considerable comfort.
His disposition was naturally cheerful, and his consti-
tution had not yet become very seriously injured by
the disease.
In the \Yinter of 1812 — 13, 1 was called one night
out of bed, and found him complaining of great pain,
attended with considerable fever, and with great ex-
ertion, he could pass but a very small quantity of
urine. I attempted to relieve him by the usual plan of
ENLARGED PROSTATE. 263
passing the catheter, but, for the first time during my
long attendance, I could not succeed. A very consider-
able hemorrhage from the urethra followed my re-
peated eflbrts to introduce the instrument. As I used
the sum elastic catheter, and was confident that no
force had been employed, sufficient to injure the ure-
thra, I referred the hemorrhage to a turgid and inflamed
state of the urethra, and was rather pleased with its
occurrence, believing that it would have a salutary
influence on the local inflammation. In this I was not
disappointed. Slight bleeding occurred through the fol-
lowing day; the warm bath with venesection was em-
ployed; the bowels were opened; opiates were admi-
nistered; and, as the inflammation subsided, the urine
was discharged, and temporary relief was experienced.
About this time he was deprived of his wife, by a
short and severe illness. This domestic affliction was
followed by an aggravated form of his primary dis-
ease. The irritable state of the urinary organs required
frequent efforts to pass small quantities of urine, by
night as well as by day.
Dr. Griffitts and myself w^ere often earnestly en-
treated to render him, if possible, some effectual relief,
but our united efforts proved vain. His general health
sunk under his accumulated sufferings; from a portly
old man, of a healthy and rather fforid countenance, he
became pale and emaciated; hectic irritation ensued,
and all that remained within the power of his medical
attendants, was to smooth his passage to the grave.
For a considerable time before the death of the pa-
tient, the catheter could not be passed into the bladder;
but, after the paroxysm which followed the death of his
264 TREATMENT OF
wife, he had no attack of retention of urine, requiring
immediate rehef.
Dissection.
A post mortem examination revealed the true state
of the case. The prostate gland was greatly enlarged —
the third lobe particularly so, — and the muscular coat
of the bladder presented a fine specimen of those large
bands which resemble so strongly the musculi pectinati
of the heart.
CASE XVII.
NOTE.
The subject of the present note was an old and re-
spectable merchant, of a very attenuated appearance?
remarkably correct in his habits, and precise in his
movements. He had never entered the married state,
and in the space of seventy years had scarcely ever
received a visit from a physician.
I was called to visit him at Moorestown, N. J. in
consultation with my departed friend Dr. John Stokes.
The following was the history of the case: his disease
commenced about two years before my visit. He had
a disposition to pass urine more frequently than usual;
it had gone on increasing until it had arrived at a point
of extreme distress, which confined him to his cham-
ber, and generally to his bed.
His inclination to void urine seemed constant, and
but a very small quantity was passed at each effort. He
ENLARGED PROSTATE. 265
told me that sometimes he was under the necessity of
urinating upwards of thirty times in the course of one
night.
On introducing the finger per anum, I found his
prostate gland very much enlarged; it was evidently of
a tuberculous structure. I succeeded in passing a small
gum elastic catheter into the bladder, through which
upwards of a pint of urine flowed, to his great relief.
The catheter was allowed to remain in the bladder
until my next visit, which I paid in three days. I found
the patient very much relieved since the introduction
of the catheter; it was withdrawn, and another intro-
duced, with directions to renew it frequently. I did not
visit him afterward; but understood from Dr. Stokes,
that after the first introduction of the catheter, he suf-
fered but little pain, though his system sunk from con-
stitutional irritation, and he died in a few weeks.
Passage of the Catheter m Enlarged Prostate.
In the chapter on the catheter I shall endeavour to
lay down rules for the introduction of the instrument
in cases of a common character. As this operation,
in cases of enlarged prostate gland, involves some im-
portant views, it is deemed proper to devote a little
space to its special consideration in this place.
In the preceding pages, I have endeavoured to give
a clear idea of the enlargement of the third lobe of the
prostate gland, and have illustrated it by plates. This
enlargement forms a triangular body, with a wide base.
34
266 TREATMENT OF
The general directions for the use of the catheter will
apply equally well to cases affected with this disease,
until the instrument arrives at the extremity of the
prostatic portion of the urethra. If any difficulty occurs,
the introduction of the finger into the rectum will ena-
ble the surgeon to give such a direction to the point of
the catheter, (either by pushing it up toward the sym-
phisis pubis, or toward either side of the gland,) that it
will enter so far within this portion of the canal, as to
prevent the point from being felt. He has now arrived
at the most difficult part of the operation, and the fin-
ger in the rectum can no longer aid him. The instru-
ment may be made to pass forward until its further
progress is arrested by the inflamed and tense third
lobe, which acts like a valve in closing the aperture of
the bladder.
The position of the point of the catheter, though it
can no longer be felt, is well understood by the expe-
rienced surgeon. It is firmly pressed against the en-
larged third lobe at its base. If an improper degree of
violence were used with a silver catheter, it might pos-
sibly force its way through this part of the gland into
the bladder. " Arte non vP'' is here the proper maxim.
Instead of using force, the operator must try to elude
the difficulty by referring to the exact position of the
parts. By withdrawing the stilet, he may sometimes
succeed in causing the point of a flexible catheter to
advance towards the symphisis pubis, and thus slip
under the third lobe into the bladder. Sometimes the
silver catheter may be so directed as to cause its point
to take somewhat the same direction, by drawing it
gently but firmly up toward the pubis; while, at the
ENLARGED PROSTATE. 267
same time the handle of the instrument is depressed as
far as possible.
Should these methods fail, an attempt may be made
to cause the catheter to ascend into the bladder by the
side of the lobe, as there is a cleft on each side, between
this lobe and the two lateral lobes. To pass the instru-
ment on either side, requires a lateral curvature of the
point of the catheter, and in this way it sometimes hap-
pens that it enters the bladder.
I was once called in consultation to the Pennsylvania
Hospital, to a case of difficulty in passing the catheter.
The instrument with the included stilet was introduced
as far as it could be advanced, and the urine flowed out
through the instrument by the side of the stilet; but
on withdrawing the latter, the flow of urine immediately
ceased, and on again introducing it, it was resumed. I
mentioned to my colleagues, that I believed the prostate
gland to be enlarged, and that the third lobe closed up
the passage at the neck of the bladder, eflectually pre-
venting the complete entrance of the instrument. That
when the stilet was in the catheter, it raised up the
third lobe, which acted as a valve, and permitted the
discharge of urine by the side of it; but when it was
withdrawn, the elastic catheter not being sufficiently
firm to resist the closure of the orifice by the valve-like
third lobe, the flow of urine ceased. The patient and
his friends being afraid of an operation, he was taken
out of the Hospital, and soon after died under the care
of Dr. Barton.
On examination after death, the case presented the
appearances which had been supposed to exist. This
case led me to the contrivance of the apparatus illus-
trated in pi. 4. fig. 1 and 2.
268 TREATMENT OF ENLARGED PROSTATE.
This apparatus consists of, first, a flexible metallic
canula, (fig. 1,) with a solid beak, but furnished with one
eyelet hole, (a.) corresponding in position with the two
little notches (5.) on the elevated rim of the instrument.
The eyelet hole communicates freely with the cavity of
the barrel of the canula toward the open extremity of
the latter. Toward the beak, the groove formed by
the continuation of the canal, terminates in an inclined
plane rising toward the inner end of the eyelet. —
Second, a flexible elastic catheter, which will readily
enter the bore of the canula, and which, when thrust
forward as far as the eyelet, is raised by the in-
clined plane, and compelled to shoot out through the
eyelet hole, so as to receive a rapid curvature in that
direction, taking the position represented in fig. 2. The
point of the flexible elastic catheter being seen at c.
It will be perceived that the indications fulfilled by
this apparatus are few and simple. The canula is suffi-
ciently ductile to take and retain any curvature that
maybe required in its introduction, and it is sufficiently
firm to push up and support the third lobe, while the
flexible elastic catheter seeks a passage through the
space thus rendered free. Before the introduction, the
eyelet hole may be made to present forward, or to either
side, thus causing the catheter to take a corresponding
curvature in any required direction. The notches on
the rim of the canula indicate to the surgeon, at all
times, the actual position of the eyelet. This instru-
ment is proposed for trial. Candor requires that I
should state, it has not yet been tested by experience.
SECTION IX.
RETENTION OF URINE FROM PRESSURE ON THE SPINAL
MARROW.
It is a fact familiar to most practitioners, that pres-
sure on the medulla spinalis is invariably attended
with paraplegia and a retention of urine. This pressure
may be produced by various causes.
It is witnessed in surgical practice in cases of severe
injury inflicted on the spine, producing fracture or dis-
location of some of the vertebrae. In violent concussions
of the spine, attended with effusion of blood within the
theca vertebralis. In scrofulous affections of the bones
of the vertebrae, resulting in the formation of matter
within the cavity, &:c. I have also seen this state of
things occurring in the progress of diseases, which fall
more particularly within the province of the physician.
Rheumatic or gouty affections may either suddenly
or gradually cause pressure on the spinal marrow, and
produce paraplegia and paralysis of the urinary blad-
der. When it is recollected how peculiarly liable are
the joints to be attacked with gout and rheumatism, it
is rather surprising that the joints of the vertebrae are
so rarely affected in this way. Thus gouty concretions
about the fingers not unfrequently produce great en-
largement and deformity of the parts, accompanied with
anchylosis. The same thing, I have no doubt, may take
place in the spine; but, happily, its occurrence is very
rare. When it does occur, the bladder becomes involved,
and the catheter is required. The disease may be mis-
270 RETENTION FROM PRESSURE
taken for an idiopathic affection of this organ, when in
reaUty its true seat is in the medulla spinalis: as in the
following case.
CASE XVIII.
In the year 1816, I was requested to visit an aged
and most respectable matron, the wife of a farmer, re-
siding thirty miles from Philadelphia. Her medical
attendant, a highly respectable physician, was treating
the case as a primary affection of the kidneys or bladder;
and when I was called, she was under the use of a de-
coction of uva ursi.
On examination, I found that she laboured under pa-
raplegia, and that the affection of the bladder was sim-
ply a consequence of serious and deep-seated affection,
causing pressure on the spinal marrow. She w^as afflicted
with rheumatism, and upon an accurate investigation
of the case, I felt satisfied that the disease must have
arisen from the thickening of the parts about the ver-
tebrae, gradually inducing pressure on the spinal mar-
row, which resulted in paraplegia. This patient died;
but I believe no post mortem examination was made.
I have seen paraplegia suddenly induced, and depend-
ing, as 1 have supposed, either upon severe inflamma-
tion terminating in effusion within the theca vertebralis,
or upon the sudden cflfusion of blood, as in apoplexy.
ON THE SPINAL MARROW. 271
CASE XIX.
In the winter of 1825—6, T. W., a young man en-
dowed with an uncommonly intelhgent mind, and an
equally amiable disposition, whose promise of talents
and usefulness was of no common order; was attacked
one night, with most violent pain in the lumbar region.
He was one of my private pupils, and resided with his
father. His suftering was so intense, that Dr. Harts-
home, who resided in the immediate neighbourhood,
was called to him in the night, and prescribed for him.
Soon after it was discovered that he was in a state of
paraplegia. His uncle, the late Dr. S. P. Griffitts and my-
self, saw him, with Dr. Hartshorne, on the following
morning. The paralytic state of his bladder required the
regular use of the catheter. The patient gradually reco-
vered, so far as to be able to walk about, but nearly two
months elapsed before he could leave his bed. There
was always a perceptible weakness in his lower extre-
mities. He graduated in the University of Pennsylva-
nia, and commenced practice, but in the spring of 1830,
he died of pulmonary consumption.
Paralysis of the bladder produced by pressure on the
spinal marrow, may be followed by ulceration and lesion
of the oriran. The abstraction of nervous influence
from the bladder, has a tendency to weaken its vital
energies. The perfect coaptation, and harmonious
action of the different parts of the organ are interrupted,
and irregular action ensues. Inflammation takes place,
but instead of being phlegmonous and restorative, it is
272 RETENTION FROM PRESSURE
erysipelatous and destructive. The ulcerative process
follows as a consequence. The bladder yields to a
solution of continuity in its structure, which under a
combined and vigorous action of all its constituent
parts, would have been successfully resisted. I believe
this fact, and probably the explanation here offered has
been published within a few years by an English phy-
sician. I know not where to refer, or I would surely do
full justice to the author.
A highly interesting case, illustrating this state of
things, occurred in my own practice.
CASE XX.
Injured Spine — Inflammation and Ulceration of the
Bladder.
■ In the spring of 1819, C. H. P., a young man pos-
sessing great muscular activity, who is reported to have
performed some extraordinary feats in running and
jumping, met with the following accident, which caused
his death.
One night, on returning to his lodgings, he placed
his arm round a tree before the door, bent his body
backwards, and commenced the operation of whirling
himself round with great velocity. While thus engaged,
he was suddenly seized with a sense of heat, (as he
described it,) in his right side, followed by excruciat-
ing pain. He walked into the house, and the family
supposed he was affected with colic.
The family physician, Dr. Caldwell, was called, and
ON THE SPINAL MARROW. 273
some blood was taken from his arm. About half an
hour after the attack, he became perfectly easy; but by
this time, he was in a state of paraplegia.
I was called about forty-eight hours after the acci-
dent, for the purpose of introducing a catheter into the
bladder, which was much distended, as he had passed
no urine. On examination, it appeared that he had a
slight degree of power over the muscles of the left leg
and thigh — ^just enough to enable him to give very
slight motion to the limb. — The right leg and thigh
were perfectly paralysed. He had no power over the
bladder. He was sensible of a slight touch on the para-
lysed limbs; but could bear to be pinched without
pain. This insensibility to pain extended up the spine
nearly to the neck. The neck itself possessed natural
feeling — also the arms.
The case obviously resulted from pressure on the
spinal marrow, most probably arising from effusion of
blood within the theca vertebralis. On this point there
was a perfect coincidence of opinion in the consulta-
tion. It was concluded to attempt relief by changing
the system with mercury, with the hope of promoting
the absorption of the effused blood; and, if the state of
the system required it, to bleed the patient occasion-
ally. The mercurial treatment failed in producing ptya-
lism. We now applied four large caustic issues to the
spine; one on each side of the upper dorsal, and one on
each side of the lumbar vertebrae. Purges were freely
used, with the hope of promoting absorption. Dr. T.
T. Hewson was joined with us in consultation, and con-
curred in the plan of treatment.
At one time we were flattered, in consequence of his
being able to move the right great toe. Several weeks
35
274 RETENTION FROM PRESSURE
before his death, he complained of considerable pain in
the right iliac region. It did not appear to extend be-
yond the linea alba. About a week before his death
this pain increased; his abdomen became tympanitic;
his pulse was more frequent; he had frequent nausea;
his countenance sunk; and his strength failed.
From the time of the accident there was a necessity
for the use of the catheter, and towards the close of the
case, the bladder was so loaded with thick, bloody, and
offensive mucus, that a very large catheter was required
to draw off the urine. It was found necessary some-
times, cautiously to inject strained tepid water, which
aided in bringing away large quantities of mucus.
About forty-eight hours before death, but a small
quantity of urine could be obtained through the cathe-
ter. On examining the bladder from the rectum, it
appeared enlarged, and on pressing the finger against
it, I received the idea that it was filled with mucus.
Instead of being elastic, as when distended with urine,
it appeared to be indented by the finger, as if it were a
piece of dough. A few hours before death, he said
something had suddenly given way. He appeared to
be in great distress for some time. All pain finally left
him, and he died remarkably easy, after an illness of
about five weeks.
Dissection.
On the day following his death, Drs. Caldwell and
Hevvson, and myself met; also my pupils, with the pre-
sent Dr. George M'Clellan, who was a friend of the
deceased. At my request he undertook the examina-
tion.
Abdomen. — The intestines were found agglutinated
ON THE SPINAL MAKROW.
275
by adhesive inflammation, and m'ine was discovered in
the cavity.
The Bladder exhibited evidences of great inflamma-
tion, which had run on to suppuration. There were two
ulcerated openings in it. The largest of these was on
the right side. It admitted the finger very readily. The
inner surface of the bladder was covered with mucus,
and a gritty concretion was observable, principally to-
ward the neck of the bladder. The w hole viscus was
greatly thickened, and adhered to the contiguous parts.
The ulcerated opening on the right side of the blad-
der was attached to a portion of intestine, in which the
ulcerative process appeared to have just commenced.
There was found an effusion of blood between the
layers of the peritoneum, exactly in the part where the
patient complained of the sudden sense of heat at the
time of the accident.
Spinal column. — The vertebrae were sawed through,
and the spinal canal exposed, without any morbid ap-
pearances being presented. We were ready to doubt
whether any discovery could be made.
A considerable portion of the spinal marrow was dis-
sected out, and on making a transverse incision through
it, there was a clear illustration of the case. A portion
of blood had been effused in the very centre of the spinal
marrow; it w^as about three inches in extent, and was
found in that portion of the medulla which corresponds
to the upper part of the dorsal, and the lower part of
the cervical vertebra.
CHAPTER II.
ON THE CATHETER.
There are some preliminary matters connected with
the catheter which, though apparently of small conse-
quence, will, in the aggregate, be found of importance
to the young practitioner.
Catheters, as we have them, may be divided into three
classes: — the silver; the flexible metallic; and the flexible
gum catheters. Every surgeon should be provided with
some of each kind. I find it most convenient to have
three silver stilets; from a large to a small size. The
silver is much more ductile than iron, and can be made
to receive any degree of curvature that may be re-
quired, with greater facility. If left in a catheter when
the internal surface is wet, it is not likely to rust and
destroy the instrument.
To illustrate the subject, I have been accustomed to
exhibit to my pupils a flexible catheter w^hich I bought
many years ago for two dollars and fifty cents. Now,
a dozen may be procured for half that sum. For a
young surgeon not very flush of money, such an instru-
ment was, at that time, quite an acquisition. It served a
most excellent purpose on several important occasions;
but it was laid aside one day, with the iron stilet within
it. Sometime after this, on attempting to put it in requi-
sition, it was found, that in consequence of the oxida-
tion of the iron, it was impracticable to withdraw the
ON THE CATHETER.
277
stilct; which has never been done, up to the present
time. Thus my catheter was rendered useless.
No surgeon should ever leave his house without hav-
ing catheters about him, especially if he is to go into
the country. It would be easy to cite cases to show the
importance of this rule, and to show, also, the neglect
which at one time pervaded the country practitioners
on this subject. I have long been accustomed to tell
my pupils, that although I am a man of peace, and, on
principle opposed to war in every form, yet I aliuays go
armed; — not, however, with pistols or fire-arms^ — but
with catheters, or water-arms.
I am accustomed to select flexible catheters of such
sizes, that one may be placed inside of another, and in
this way three may be fitted together. They are car-
ried in a curved side pocket of sufficient depth to con-
ceal them. The pocket must be covered, for some dis-
tance up, with buckskin, or else the catheters will soon
work their way through the linen, and may be lost.
This I know from experience.
A proper curvature for a silver catheter is a matter
of great importance. A plate in Hey's, and also in
Dorsey's Surgery is very well adapted to the purpose.
I have had for many years, an excellent silver catheter,
curved by Iley's plate. A surgeon may be placed in a
situation where he may resort to a substitute, as pro-
posed by the late Dr. Dorsey. lie took the wire from
his elastic suspenders, covered it with waxed cloth, and
succeeded in passing this instrument into the bladder.
Directions for the Use of the Catheter,
The catheter should be dipped into warm water, or
held before the fire to raise the temperature, and it
278 ON THE CATHETER.
should then be lubricated with sweet oil, or some other
unctuous matter. A large catheter, in an unpractised
hand, may be introduced more readily than a small
one. This fact is important to the young practitioner,
for he might naturally adopt an opposite conclusion. A
small catheter may be easily impeded by becoming en-
tangled in the lacunae of the urethra, which accident
sometimes causes much pain; while a large catheter
that fills up the urethra, cannot diverge from one side to
the other, and distends the canal as it advances. This
subject may be illustrated by the common operation of
giving an enema. If this be attempted by a bungling
hand, the small pipe may deviate from the centre of the
anus, and become hitched on the side of the sphincter,
causing no little pain to the patient. If the same ope-
rator were to attempt the introduction of the finger in
ano, after lubricating it with oil, he would accomplish
his purpose without difiiculty; because the finger dilates
the parts as it passes onward.
In the introduction of the catheter into the bladder,
an accurate anatomical knowledo-e of the relative situa-
tion of the contiguous parts may prove of essential ser-
vice. One of the first difficulties is met with in passing
the instrument under the arch of the pubis. It is some-
times necessary to pass it downward as far as it will
advance, with its convex part toward the pubis; then,
drawing the penis upon it, to give it a semi-rotatory
motion, pushing it gently forward at the same time,
until its concave surface is presented toward the pubis
in a line with the linea alba.
After the catheter has passed under the pubic arch,
it will soon enter the membranous portion of the ure-
thra. If any difficulty arises at this point, two modes
ON THE CATHETER. 279
may be adopted to relieve it. The index finger should
be introduced into the rectum, and tlic point of the in-
strument may be felt through the bowel in the mem-
branous portion. While the operator holds the instru-
ment with one ' hand ready to push it forward, he can,
with the finger of the other hand, elevate the point di-
rectly in front of the opening in the prostate gland.
This will generally prove successful, and the catheter
w^ll then enter the bladder. The surgeon may also give
a lateral direction to the point of the instrument, if
required; and this is sometimes of the utmost conse-
quence in a diseased state of the prostate gland.
If a flexible gum catheter with a stilet be used, the
curvature of the instrument may be varied, and its
point turned to the upper side of the urethra by gently
withdrawing the stilet a little distance. This may be
made clearly to appear, by drawing a stilet from a ca-
theter before its introduction.
Some of the flexible metallic catheters have a small
probe-pointed projection beyond the common round
termination, so as to enter a contracted or strictured
part, and lead the way before the instrument. Some
catheters are formed small at the point, and very gra-
dually increasing in size toward the other end. The
practice, introduced by my friend Dr. Physick, of ap-
pending a portion of waxed bougie as a point for the
catheter, (as directed in Dorsey's Surgery,) and allow-
ing it to adapt itself, and become gently insinuated into
the part where the obstruction exists, is one entitled to
the greatest attention, and is admirably adapted to
elude some of the most serious difficulties and dangers
connected with retention of urine. The distension of the
urethra by the injection of warm olive oil, has been
^80 ON THE CATHETER.
tried by my friend Dr. Thomas T. Hewson with suc-
cess.
In all operations with the catheter, the greatest
care must be observed to avoid improper force. The
maxim '•^ arte non vP is here particularly applicable.
For want of attention to this rule the urethra may be
lacerated by unskilful hands, to the no small pain and
danger of the patient. The variation of curvature, by
using a variety of silver stilets, some of them with a
lateral bend, as recommended by Dr. Dorsey, I consider
very important. I have also, upon the recommenda-
tion of Home, attempted to give a permanent lateral
curvature to catheters, by keeping them for a long time
on stilets variously modified. Sometimes the curvature
required is very great. I once saw Dr. Physick intro-
duce a catheter in a case of great difficulty, in which
he bent the instrument nearly double. Sometimes ca-
theters may be made to pass easily into the bladder
without any stilet.
I consider, as a general rule, the recumbent posture
greatly preferable to the erect position in the passage
of the catheter. The straight catheter, as recommended
particularly by the French surgeons, I have no doubt
is well adapted to certain cases, when it is employed
by a surgeon familiar with its use.
When 1 have met with great difficulty in passing the
catheter into the bladder, and have finally succeeded, I
have generally permitted it to remain for a few days,
secured by a tape passed round the penis, and closed
by a cedar plug, which enables the patient to draw off
his urine at- pleasure. In the early part of the treat-
ment, if the instrument causes no unusual pain, I have
a preference in permitting it to rest in the canal for
ON THE CATHETER. ii81
several days. It appears to -nie that the urethra be-
comes inured, in this way, to the presence of the instru-
ment, and is moulded in such a manner that less sub-
sequent difficuky is experienced in its introduction.
But after the first effects of retention have passed over,
I prefer the removal of the catheter directly after draw-
ing off the urine; repeating the introduction every
morning and evening, or oftener if required. Advantage
may now be derived from encouraging the patient to
make moderate efforts to relieve himself in the natural
way. In some instances, weeks, or even months may
elapse before the use of the catheter can be dispensed
with.
The slowness of return to a healthy condition, in
many cases of retention, cannot, in my opinion, be re-
ferred to a paralytic condition of the urinary organs.
If this condition were present, incontinence of urine
would be the result; but this is not the case. I have fre-
quently requested my patients, while the catheter was
in the bladder, to make efforts to expel the urine. The
force with which it is propelled through the instrument
on such occasions, gives decisive evidence of muscular
power in the bladder. The perfect freedom with which
a "large catheter may be passed, shows clearly that no
stricture or mechanical impediment is in the way. What
then is the cause of the difficulty? I am inclined to at-
tribute it to the loss of those sympathetic and harmo-
nious actions between contiguous parts, which, in a
healthy condition, are so nicely adjusted, and so accu-
rately maintained. I have either read or heard a simile
which places the subject in a clear light; whence it is
derived I am now unable to state. The bladder and
urethra are compared to two horses in a wagon who
36
282 DIFFICULTY OF PASSING THE CATHETER
are false to the draft; when one pushes forward, the
other pulls back, and when the latter advances, the for-
mer pays him in his own coin, and refuses to move;
hence it requires no little skill and patience in the
driver to adjust the difficulty. It is, I presume, on the
principle of restoring the harmonious action of conti-
guous parts, that Dr. Gibson has suggested, in cases of
retention, the practice of pouring water from a consi-
derable height into a vessel beneath, in the presence of
the patient, a practice which he has tried with benefit,
especially in infants. He was led to adopt this course
from the custom of experienced ostlers, who place fresh
straw under a horse, and cause a rustling noise, which,
it is well understood, invites the animal to a discharge
of urine.
SECTION I.
DIFFIOULTY IN THE PASSAGE OP THE CATHETER PROM AN
EFFUSION OP BLOOD.
Difficulties are sometimes experienced in passing the
catheter, from unsuspected causes. It is very important
for the surgeon to be aware of these, and of the means
of overcoming them.
I shall first notice the eflfusion of blood into the ure-
thra. In the course of my practice, I have sometimes
met with an impediment in the passage of the catheter,
which I was at one time unable to explain.
When the instrument has been passed as far down
as the arch of the pubis, instead of keeping its usual
FROM AN EFFUSION OP BLOOD. 283
course, I have been sensible that the point took a late-
ral direction, and have been impressed with a fear, that
if I were to continue to push it forward, the uretha
might be pierced on its side. A case occurred to me
some years ago, which enabled me to ascertain the
cause of this difficulty.
CASE XXI.
3d mo. 21st, 1819. I was attempting to pass the ca-
ther, in the case of R. D., an old and respectable citi-
zen, who had been for a long time afflicted with calculi
in the bladder, and for whom I had frequently passed
the instrument without difficulty.
In this instance I was unexpectedly foiled in my
first attempts. I perceived some blood at the ori-
fice of the urethra; this I considered of no import-
ance, and pushed in the instrument as usual. The
catheter carried something before it, as it passed
down the canal, and after entering for a short dis-
tance, it w^as evident that the urethra was completely
obstructed. On withdrawing the instrument, blood
again rose to the orifice; it was dark and firm, and
in a coagulated state. On taking hold of the project-
ing portion with my finger, I drew out a mass of
coagulated blood, several inches in length, which
must have nearly filled up the urethra. The catheter
was again introduced. It entered without difficulty,
and passed along under the arch of the pubis; here
it was again resisted, (so far as I could judge by
the sense of touch,) by the same kind of mass. On
284 DIFFICULTY OF PASSING THE CATHETER
firmly, yet carefully pushing the instrument forward, it
took the lateral direction, which I had often before
noticed, but never so fully understood.
I now believed that the urethra was distended at this
part with coagulated blood; the catheter could not pass
through its centre, but took a course between the
coagulum and the side of the urethra, thus preventing
the entrance of the instrument into the bladder. I suc-
ceeded in introducino; it a few hours afterwards.
A short time after this, the old man died, after hav-
ing suffered most severely from his disease. I examined
the body after death, in the presence of Dr. Hartshorne.
The prostate gland was very much enlarged; and I
took eight calculi from his bladder. Their average size
was that of a hickory nut: they were rough on the sur-
face.
Remark,
Reflecting on this case, I came to the conclusion,
that in a similar instance, I would attempt to wash
out the blood from the urethra, by the injection of
tepid water through a small syringe.
A portion of water should be injected, and retained
in the urethra by closing the orifice. By this method
the water is brought in contact with the coagulum, a
portion of which will be dissolved; this is evacuated,
and the operation repeated, until the whole mass is
removed.
Another source of embarrassment connected with
efiiision of blood, has fallen under my notice. In this
instance the catheter is not obstructed in its passage to
the bladder, but the difficulty is to be found in the bladder
FROM AN EFFUSION OF BLOOD. 285
itself, and, until the true character of the case is ascer-
tained, the patient is involved in suffering and danger,
and his medical attendants in doubt. The following case
will illustrate my meaning.
CASE XXII.
In the summer of 1814, I was requested to visit a
respectable old farmer residing near Bustleton, who
was labourincr under retention of urine. His bladder was
distended, and numerous efforts to introduce the cathe-
ter had failed. It so happened that I was instrumen-
tal in procuring relief for the patient. I passed the
catheter into the bladder, drew off the urine, and re-
turned to the city, leaving him under the care of his
physicians, Drs. Worthington and Smith.
Nearly two weeks after this my attendance was
again requested, in consequence of the occurrence of
certain symptoms which it was difficult to explain. His
medical attendants found no difficulty in introducing the
catheter, and some bloody urine would occasionally be
discharged through it. Still the patient was not relieved,
as he had generally been, and the bladder appeared to
be still distended. On examination I found considerable
fulness above the pubis. The symptoms of retention
were not so violent, as in the first instance, but there
was evidently some obscure mischief.
My first object was to ascertain whether the catheter
actually entered the bladder. I introduced it with the
greatest ease, but no urine followed. On withdrawing
the instrument and examining its eye, I found it con
286 DIFFICULTY OF PASSING THE CATHETER
tained a portion of coagulated blood. This immediately
led to the suspicion that the bladder was filled with
blood. To test the correctness of this conjecture, I
returned the catheter into the bladder, and then bv
means of a syringe, injected very cautiously a portion
of warm water. The finger was then applied to the end
of the catheter in order to prevent a return of the wa-
ter, supposing that if blood were the cause, a por-
tion of it would be dissolved. On removing the finger
in a few minutes, bloody water escaped through the in-
strument, and my suspicions were realized.
The whole case was now perfectly clear. I repeatedly
injected warm water, retaining it as before, and then
permitting it to escape; after every discharge the quan-
tity of warm water could be increased. In this manner
the blood was gradually washed out of the bladder, to
the great relief of the patient, and very serious conse-
quences were averted.
It sometimes happens, that the surgeon is called upon
to pass the catheter, in cases complicated with inflam-
mation of the urethra, or of the neck of the bladder.
This condition may either be the original cause of the
retention, or the result of long-continued and injudicious
efforts to introduce the catheter in unskilful hands. In
these cases the system is generally considerably excited,
the pulse is active and febrile, the skin is hot, and the
patient very restless. Under these circumstances, I
have generally made slight attempts to introduce the
catheter; but if it did not pass easily, I have desisted
and advised the reduction of the inflammation by ve-
nesection, leeches to the perineum, &c. The warm bath
FROM AN EFFUSION OF BLOOD. 287
and opiates, and particularly a combination of calomel
and opium, in the proportion of eight or ten grains of
the former to two or three of the latter, have had, on
some occasions, a very happy effect. After pursuing
this course for a few hours, the threatening symptoms
will generally yield. When the inflammation and con-
striction of the urethra are removed, the instrument
may be passed without difficulty.
CHAPTER III.
STRICTURE OF THE URETHRA.
It is not my intention to offer a systematic history
of this disease in its multiphed forms; but to confine
my observations within defined Hmits, referring to sys-
tematic writers for such parts of the subject as may be
left untouched.
A stricture consists in a diminution of some part of
the canal through which the urine passes from the
bladder. The disease is often first observed by a tem-
porary difficulty in voiding urine, which subsides, and
leaves the part in a natural state. The urethra, in this
form of the disease, may take on a sudden spasmodic
action, whereby the size of the canal is diminished, caus-
ing retention of urine, and a difficulty in the introduc-
tion of the catheter or bougie.
A difference of opinion exists among writers, upon
the nature of this spasmodic contraction of the urethra.
Some attribute it simply to elasticity in the structure of
this part; while others consider it as the result of mus-
cular contraction. Although distinct muscular fibres
may not be demonstrated in the human urethra, yet
they may be traced in larger animals, and we are thus
led to infer their existence. The effects of muscular
contraction are so clearly manifested in the urethra in
various ways, that my own mind is satisfied on this
STRICTURE OP THE URETHRA. 289
point. The existence of the thread-like stricture ap-
pears alone sufficient to establish the fact.
We see this principle more obviously exemplified in
the intestinal canal. In cases where death has resulted
from long-continued and violent spasm in this part, a
post mortem examination exhibits parts of the intes-
tinal tube, in which a diminution of cahbre has oc-
curred, presenting an appearance very similar to the
effect of a tape drawn around the bowel, so as nearly
to obliterate the passage. The same appearance is ob-
served in stricture of the urethra.
The frequent repetition of spasmodic action in the
urethra is often followed by inflammation and thicken-
ing of the affected part, and may finally result in a per-
manent stricture.
This more durable form occurs also in the intestinal
tube, under like circumstances. I was in the practice of
attending an intimate friend, of this city, who was a
plumber by trade, and was subject for many years to
frequent attacks of colica pictonum, and gout, of which
he finally died. A post mortem examination exhibited a
firm and permanent stricture of the colon.
The same condition occurs in the oesophagus. I well
recollect, while I was a pupil, the case of a lady who
had been for a long time affected with stricture of the
oesophagus, and who died from inanition under the care
of Dr. Wistar. On examination after death, a portion
of the tube was so much thickened, that it would
scarcely admit a probe.
Strictures of the urethra are accompanied with a
corresponding diminution in the stream of urine. In
the first stage of the disease this symptom may scarcely
be noticed; but as the size of the canal diminishes, the
37
290 STRICTURE OF THE URETHRA.
Stream becomes forked or spiral, like a corkscrew; a
considerable time is required to discharge the urine;
and finally it dribbles away in drops.
The patient generally experiences more or less pain
at the stricture, and pain is sometimes complained of
near the extremity of the penis. A gleety discharge is
also a common attendant on the disease.
When a stricture is so tight as nearly to close the
canal, exposure to cold, irregularities from intemperate
drinking, with other causes of an irritating character,
may produce a complete obstruction and retention of
urine.
In some irritable individuals, a train of alarming
symptoms may be induced by the introduction of the
bougie. I once attended a nervous old bachelor with
stricture. In attempting to pass a bougie he was sud-
denly attacked with a chill, and his symptoms were so
extremely violent, that I felt seriously uneasy for the
result. It resembled very much the chill of a malignant
intermittent, which sometimes prostrates the patient
below the point of reaction, and speedily terminates in
death. Under prompt tranquillizing and restorative
treatment he recovered.
The constant irritation to w^hich the urethra is sub-
jected in cases of stricture, may be readily propagated
to the bladder, producing such frequent calls to urinate
that the real character of the disease may be over-
looked. The kidneys or bladder may be suspected as
the primary seat of a complaint, which is in reality
located in the urethra.
Dr. Wistar was accustomed to relate to his pupils
the case of an old and most respectable citizen, who was
under his care with stricture of the urethra. He advised
STRICTURE OF THE URETHRA. 1291
the use of bougies, &c. To this practice the patient
was extremely averse, neither could he comprehend its
necessity, inasmuch as he believed his disease was
"^raye/." Under this impression he travelled about,
visiting a number of mineral springs, whose waters are
famed for the cure of various complaints. He returned
home disappointed, and not improved. He now took
Dr. Wistar's advice; the bougie was employed, and the
patient was restored to health.
Instances of this kind have occasionally fallen under
my own observation. I well recollect a patient whom
I attended with stricture, whose bladder was so irritable
that he was subjected to great inconvenience from fre-
quent calls to urinate. The use of the bougie soon
overcame the stricture, and afforded him relief from
those symptoms.
The testes may also be involved in serious disease
from a stricture in the urethra. This I have repeatedly
witnessed in hospital practice. There is reason to fear
that some patients have been subjected to pain and mu-
tilation, who might have been saved from both, had the
practitioner been fully acquainted with the primary seat
of the mischief.
I have received much valuable information on this
subject from the work of " Ramsden on the Testicles,"
an author who has devoted much time to its investiga-
tion.
As a general rule, strictures exist about the bulb of
the urethra, yet they sometimes form in other parts of
the canal. I have seen two cases within a very short
distance of the point of the urethra.
SECTION I.
TREATMENT OF STRICTURE.
The more simple and manageable form of stricture,
lies within the reach of mechanical dilatation by the
bougie. I shall say but little on these cases, referring
the reader to the numerous works which treat at large
upon this subject. It may be remarked, that even in
some very discouraging cases the use of the bougie will
generally succeed, at least in relieving the patient, if
it will not produce a radical cure. Even though the
surgeon is obliged to use a very small bougie in the
commencement of the treatment, yet by perseverance
and gentleness the obstruction gradually yields.
At the first introduction, the instrument should be
allowed to remain but a few minutes, as the patient
generally suffers severe pain. As the sensibility of the
part diminishes, the bougie may be longer retained,
until at last an hour may elapse, without the patient
appearing to suffer pain or inconvenience. It is gene-
rally necessary to begin the process of dilatation with
a very small bougie, gradually increasing the size until
an instrument of maximum size can be introduced. The
operation should be repeated daily. After the removal
of the stricture, a large sized catheter or bougie should
be occasionally introduced, with a view of preventing
a return.
It has been previously stated, that patients with stric-
ture are very liable to an aggravation of the disease
from exposure to cold and other causes, and that a
TREATMENT OF STRICTURE. 293
complete retention is sometimes the consequence. I
have occasionally seen patients in a very critical situa-
tion from such an occurrence. The bladder has been
very much distended, forming a tumour above the pubis,
attended with pain, inflammation, and fever. In these
cases the indications consist of such measures as are
calculated to reduce fever and inflammation, allay pain,
and procure relaxation. Hence general bleeding, with
the application of leeches to the perineum, the warm
bath, either generally or locally to the affected part,
with the exhibition of calomel and opium, will constitute
the general means of relief. Added to these, the use of
bougies and catheters, of diflferent dimensions, should
be tried.
In some of these cases, where I felt greatly dis-
couraged, I have witnessed an unexpected and gradual
abatement of the symptoms, the stricture has yielded
to the remedies, and the patient become able to dis-
charge his urine. Although the pain experienced in this
form of the disease is considerable, yet it is not gene-
rally so intense as that felt by patients with distended
bladder suddenly induced for the first time. Perhaps
this circumstance may be referred to the fact, that
some patients with stricture of long standing, habitually
retain a portion of urine and thus the bladder becomes
so accustomed to the presence of an unnatural quan-
tity of the fluid, that its irritating effects are in some
degree diminished.
The following case, which fell under my observation
during last w inter, presents an example of the condi-
tion noticed above.
294 TREATMENT OF STRICTURE.
CASE XXIII.
1st mo. 26th, 1834. .1. S., a stout muscular man, who
had been the captain of a vessel for many years, had
been the subject of permanent stricture for the last six
years; for which he has occasionally used a bougie. I
was called to see him at one of the hotels, on the even-
ing of his arrival from a journey, in which he had been
exposed in a stage-coach to unusually cold and incle-
ment weather.
He had been suffering during the day, from retention
of urine, being unable to pass his water, except by drops.
The bladder was evidently considerably distended. His
pulse was active and febrile, skin hot, and he was suf-
fering great uneasiness. In addition to the stricture,
the patient was affected with a severe catarrh.
I attempted the introduction of the catheter, but
finding the stricture very firm, I desisted after slight
efforts. He was directed to be freely bled from the arm,
to have a warm bath, and to take pills of calomel and
opium.
27th. The patient has passed a restless night; blad-
der considerably distended. Has not discharged urine,
except a little by drops. The introduction of the ca-
theter was again attempted without success. I directed
free leeching to the perineum, and castor oil to open
the bowels, diluent drinks, warm bath, &c. Frequent
attempts were made in the course of the day to intro-
duce the catheter, both by myself and son, but without
success. Instruments of various sizes were tried, and
a bougie was passed down to the stricture, and retained
TREATMENT OF STRICTURE. 295
there by the patient for a considerable time. The
bowels were freely opened by the medicine; but still
we were obliged to consign the patient to another night
of suffering.
28th. No improvement; has passed a distressing night.
He was again bled from the arm, and the introduction
of the catheter faithfully tried without success. We
feared that it would be necessary to resort to the
operation of tapping the bladder above the pubis. My
friend and former pupil, Dr. Ashmead, now saw him at
my request. He had lately returned from Paris, and
had with him a great variety of instruments adapted
for cases of this description. After trying a variety of
catheters without success, he finally succeeded in pass-
ing the stricture with a silver catheter, having a taper-
ing extremity. The end of the instrument was firm
and pointed, and well calculated to enter a very small
stricture. This form of catheter is recommended by
Dupuytren, and has been frequently successful in his
hands in very difficult cases. In skilful hands it is cer-
tainly an excellent instrument; but when used by bun-
gling operators, its pointed extremity would be dan-
gerous. It is scarcely necessary to add, that this pa-
tient was relieved by the operation, and recovered his
usual health in a few days.
On the Use of Caustic in Strictures.
Some cases of stricture will not yield to mechanical
dilatation, and require to be subjected to the operation
296 TREATMENT OF STRICTURE.
of the knife or the caustic. The latter plan was re-
commended and practised by John Hunter, and after-
ward claimed the especial attention of Everard Home,
who has written a voluminous work with a view of
elucidating its beneficial effects.
The method of applying caustic is a matter of nicety
and importance. Home recommended the plan of fixing
to the point of the wax bougie, a piece of lunar caus-
tic, about half an inch in length, and about one-third
of the thickness of the usual rolls of caustic. The sides
of the caustic are to be covered by the bougie plaster,
and the extremity only exposed. Having previously
ascertained the depth of the stricture, the surgeon
dips the bougie in oil and passes it down to the stric-
tured part. It is suffered to remain on the stricture for
about a minute, and then removed. After the removal,
the patient is desired to make water. This operation is
repeated every two or three days, until the surgeon has
evidence that the stricture is destroyed.
This plan of applying the caustic is attended with no
inconsiderable trouble, in adapting the caustic to the
bougie, and sometimes difficulties have occurred in
passing it down to the stricture.
I prefer a hollow bougie open at the extremity, into
which a whalebone stilet is introduced, having fixed
on its end two pieces of silver that act like a clasp,
which readily holds a piece of caustic. This instru-
ment is used in this city. After passing it down to the
stricture, the stilet is pushed forward, and the caustic
applied directly to the part. If any difficulty occurs in
the introduction of the instrument, from its sides hitch-
ing in the lacunae of the urethra, a small solid bougie
TREATMENT OF STRICTURE. 297
may be introduced within the hollow one, and in this
way a passage may be made for it down to the stric-
ture.
Conditions in which Caustic is imjwoper.
When we consider the probable condition of the
urethra subjected to the influence of a permanent stric-
ture, by which a portion of the canal has been for a
long time very much contracted, it is easy to conceive
that by repeated and strong eflforts to pass urine through
the contracted portion, the parts behind the stricture
will become dilated, and the urine will accumulate in a
sort of pouch formed in this situation. In process of
time the sides of the canal at this point will become so
weakened as to be exposed to the danger of rupture.
When caustic is applied to a very narrow stricture,
the object in view is to destroy the part, with the ex-
pectation of a slough being separated. Before this can be
effected, the canal in the vicinity of the stricture must
become inflamed and thickened, and during the process,
the urethra at this part may be almost entirely ^closed.
Under these circumstances, very great difficulty is ex-
perienced in discharging the urine, and I have known an
almost total retention to continue for one or two days.
When a slough is detached, a slight increase is ob-
served in the size of the stream of urine, and the risk
of closure of the urethra by subsequent applications is
diminished. ^
But it may happen, that the application of caustic
may produce a complete obstruction in the passage.
The efforts of the patient to discharge urine may be so
38
298 TREATMENT OF STRICTURE.
violent that the dilated and weakened urethra, behind
the stricture, may actually burst. The urine may be ex-
tensively diffused through the adjacent cellular texture
producing the most disastrous effects.
CASE XXIV.
Rupture of the Urethra from Caustic.
While I was one of the surgeons of the Almshouse
hospital, a poor man came under my care aflected with
stricture of the urethra. It was situated some distance
anterior to the bulb, and there was an evident enlarge-
ment of the canal behind the stricture. The treatment
was commenced b}^ the application of lunar caustic to
the stricture. Soon after this, probably within forty-eight
hours from the application, while I was passing through
the ward, my attention was called to the patient. My
feelinors were shocked when I discovered that the ure-
thra had given way behind the stricture, and urine was
extensively effused through the cellular membrane of
the penis, scrotum, about the thighs, and above the
pubis. The consequence was inflammation and morti-
fication, which terminated in the death of the patient.
The termination of this case caused me great un-
easiness, inasmuch as the caustic had been applied under
my direction, and as I had reason to fear, that it had an
agency in producing the rupture of the urethra.
** Such an accident might have occurred without any
surgical interference, as will be shown in the sequel.
Yet such a case could not fail to make a deep impres-
TREATMENT OF STRICTURE. 299
sion on any practitioner, whose mind was imbued with
a just sense of the responsibihty resting upon him,
when the life of a fellow being is placed in his hands.
It has fixed my determination never again to apply
caustic to a stricture under such circumstances. I have
considered it a duty to state the case honestly, as an
instance of injudicious practice. It is the part of hu-
manity to err. I have long thought, that if medical
men were careful to relate to the profession at large, i
their failures in practice, with the reflections and con-
clusions derived from them, it would greatly promote
the common good. It would aid in forming a medical
chart in a dangerous navigation, upon which would be
discovered rocks and shoals, which v/ould prove of vast
importance to subsequent navigators.
Books abounding with successful results of practice
are numerous, and I have sometimes thought, that some
of them proved too much. They have appeared calcu-
lated to lead the sanguine and inexperienced minds of
youth into a belief, that they had only to go and do
likewise; while a moderate acquaintance with the
realities of medical life, must soon teach some im-
portant and painful lessons.
If a medical man toward the close of a long pro-
fessional life spent in observing disease, would write a
little book, composed entirely of a detail of his unsuc-
cessful cases, he would confer a lasting benefit on man-
kind.
Another condition of the urethra sometimes occurs
as a result of a small and permanent stricture, which,
if I remember rightly, has been described bv some En<T-
300 TREATMENT OF STRICTURE.
lish surgeon. Its existence is made known by the form-
ation of a tumour situated in the perineum, about the size
of a common orange when spht in half. It would seem
to be formed by distension, combined with the ulcera-
tive process. Its sides or walls are measureably de-
fended from immediate danger of rupture; yet not
sufficiently so to protect the patient from a risk of such
consequences, before the absorbents have formed an
opening through the integuments, and established an
outlet for the urine by a fistulous opening in the peri-
neum.
An example of this form of disease, once occurred to
me in the Almshouse Hospital. The patient had an old
stricture, with a tumour of this description in the peri-
neum. He was affected with complete retention of
urine. The poor fellow suffered extreme pain, and every
effort to pass the catheter failed. My colleague, Dr.
Hewson, and myself, concluded to make an outlet for
the urine by an incision.
The patient was placed on a table, and I made a
bold incision into the tumour, and gave free vent to the
accumulated urine, to his great relief. I now^ attempted
to complete the operation, by dividing the stricture by
incision, and passing a catheter through the penis into
the bladder. But such was the extreme restlessness and
resistance of the patient, that it appeared almost im-
possible to carry out the operation at this time. My
colleague joined me in giving place to our more tender
feelings, and we allowed the poor wTetch to escape
from the table. We felt well assured that he was re-
lieved from present pain and danger, and hoped that at
some more propitious period he might receive, perhaps
from other hands, the benefits of an operation for radi-
cal cure.
TREATMENT OF STRICTURE. 301
In such a case as the preceding, I should also con-
sider the application of caustic to the stricture equally
objectionable.
Rupture cf the Urethra^ and Effusion of Urine into the
Cellular Texture,
It has been previously stated, that in some bad cases
of stricture, the spontaneous efforts of the patient to
discharge his urine, have proved sufficient to rupture
the urethra behind the stricture, and to give rise to dan-
gerous symptoms from the effusion of urine.
I have witnessed a few of these cases, and have found
that if the effusion extends above the pubis, and about
the groins and thighs, that the death of the patient may
be expected, from the violence of the constitutional
symptoms.
In this accident we have an illustration of a law of
the human economy, that when urine is effused into the
cellular tissue, it will cause erysipelatous inflammation
and mortification of the parts subjected to its action.
It is also known, that the injection of wine into the
same membrane will produce similar effects. Hence the
accidents which have arisen in attempts at the radical
cure of hydrocele.
When the mortification is confined within the limits
of the scrotum, the patient may escape with his life,
being subjected to the inconvenience of a fistula in
perinco.
An instance of this kind fell under my observation
302 TREATMENT OF STRICTURE.
a few years ago, in the practice of my friend Dr. C.
D. Meigs, who called me in consultation. The patient
was affected with stricture; a rupture of the urethra
occurred behind the stricture; urine was effused; and
mortification and sloughing of the scrotum, and about
the perineum, took place.
I lately inquired of Dr. Meigs, if he could give me an
account of the present state of the case. He informed
me, that the patient recovered from the immediate ef-
fects of the accident, but that he had lost sight of him for
several years. I presume that a fistula in perineo still
exists, unless he has been subjected to appropriate
treatment.
A case most threatening in its character, yet ulti-
mately successful in its termination, came under my
notice some months past, in consultation with Drs. G.
M'Clellan, Pattison, and Hewson. The patient had suf-
fered from a stricture for some years. Dr. M'Clellan
had been called to him in an attack of complete re-
tention. The urethra gave way behind the stricture,
and urine was extensively effused into the cellular
membrane. It had evidently extended beyond the scro-
tum, and there was a tumefied state of the skin just
above the pubis.
It was ao-reed in consultation that Dr. M'C. should
make a free incision into the integuments about the
lower part of the scrotum, so as to allow of the escape
of urine, and the separation of sloughs. The case
was suspended in great jeopardy for many days, dur-
ing which time alarming hemorrhage took place from
the sloughing parts, which seemed to be arrested
by the application of the Kreosote wash. A tonic
course of treatment, with a generous diet to aid the
TREATMENT OF STRICTURE.
303
system in its restorative efforts, was most diligently
pursued; and the patient finally recovered under the
care of Dr. M'Clellan.
It has been established as a general rule, that the
effusion of urine into the cellular texture of the scro-
tum, will produce the death of the parts subjected to its
action. The following case, which is extraordinary in
its character, is introduced as an exception to the rule.
The case occurred in the practice of my friend Dr.
Gebhard, who kindly furnished me with a full detail
of it, from which the following summary has been
formed.
CASE XXV.
Ruptured Urethra — Effusion witJiout Gangrene.
1 was called in consultation with Dr. Gebhard, in the
winter of 1819 — 20, to see a little boy aged seven
years. From the age of nine months, the child had been
afflicted severely with disease, which I had no doubt
was produced by calculi in the bladder. Dr. Gebhard
had attended him on several occasions within the last
eighteen months, with violent paroxysms resembling
fits of the stone. On the day preceding my visit, the
Dr. had been called to visit him in one of his usual
attacks. On his visit the next morning, he found the
scrotum uncommonly enlarged, tense, and diaphonous.
The parts were punctured very freely with a lancet,
and urine flowed freely through the punctures.
My attendance was now requested. We continued
to watch the case with much solicitude for many days.
304 TREATMENT OP STRICTURE.
In the progress of the disease, the constitutional symp--
toms were very severe, and the danger of the Httle
patient extreme. The tongue was dry and dark, and
the pulse was frequent and feeble. The effusion ex-
tended above the pubis, and down the thighs. The skin
was tense, and a moderate blush from inflammation
was perceptible over the elevated surflice. Mortifica-
tion did not take place at any point. The bladder was
relieved from pain and distension, urine flowed through
the punctures in the perineum and scrotum, and occa-
sionally a portion was discharged through the penis*
There was no doubt that the effusion arose from a
rupture of the urethra. About the tenth and eleventh
days from the occurrence of the effusion, a striking im-
provement in his condition occurred. The tongue be-
came moist, and of a more natural colour, the pulse
improved, his restlessness and delirium subsided, and
he began to have a desire for food. The inflammation
and tumefaction of the scrotum and adjacent parts had
greatly abated; and though he was extremely feeble,
his strength gradually improved under a nutritious diet,
and in about a month from his attack he was restored
to his usual strength.
The urine was discharged more copiously from se-
veral fistulous openings about the perineum than by the
urethra.
These fistulae gradually diminished in size and num-
ber, until but one remained, which assumed a perma-
nent character.
Rem-arks.
The history of this case is unusually interesting. I
presume the original cause of the rupture may be re-
ferred to a small calculus, which in the first instance
blocked up the urethra.
- FISTULA IN PERINEO. 305
But the fact of such extensive effusion of urine, with-
out mortification, is worthy of remark. Inflammation
occurred, but it was destitute of any mahgnant cha-
racter. May not this circumstance be rationally attri-
buted to the difference in the quality of the urine,
between the adult and the child. In the former, when
brought in contact with the cellular membrane, it is
found to be an acrid, irritating fluid, spreading death
and destruction in its course; while in the infant or
child, its qualities are so bland as only to produce
healthy inflammation.
SECTION II.
FISTULA IN PERINEO.
Having alluded to some of the causes which produce
fistulous openings in the perineum, I shall briefly detail
the result of my experience in the treatment of these
cases.
Although this disease is not dangerous, yet it is ex-
tremely inconvenient and disgusting. Instead of the
urine taking its natural course through the urethra, it
is discharged through the fistulous opening. The pa-
tient is obliged, when called upon to pass urine, to
retire to the privy, and place himself in the position
required for an alvine discharge, or else be subjected
to the filthy dilemma of having his shirt and small-
clothes constantly wet.
The indications for radical cure in these cases are
clear and simple; and may be britfly defined.
3d
306 FISTULA IN PERINEO. ,
The first consists in the removal of the stricture
which lies anterior to the fistulous opening. This may
be accomplished by the liberal use of caustic, remem-
bering that as the urine has a free outlet through the
fistulous opening, there is nothing to fear from its ap-
plication.
There can be no risk of rupture of the urethra behind
the stricture, inasmuch as an opening already exists.
Having destroyed the stricture, and established the
route to the bladder, the second indication is accom-
plished by passing a succession of catheters into the
bladder, and constantly retaining them in their position,
so that not a single drop of urine shall be permitted
to pass through the fistulous opening.
Having removed the urine, the primary source of
irritation, from the sinus; the third indication consists
in breaking down its hardened walls, by the applica-
tion of caustic.
This object being accomplished, the final indication
consists in approximating the sides of the fistula, by
adhesive strips. Healthy granulations arise through the
fistula, and its sides are brought into contact. In this
way the opening is closed, the parts become consoli-
dated, and the cure is radical.
, In illustration of these views, the following cases are
presented.
CASE XXVI.
One of the worst cases of this disease, that I ever
witnessed, came under my notice in the summer of
• FISTULA IN PERINEO. 307
1820. The patient was a gentleman from the West
Indies, who came to this country to seek the advice of
Dr. Physick. Drs. Gibson, Horner, and myself were
associated with him in consultation. The opening in
the perineum was so large, as almost to foreclose the
hope of a cure. The stricture had been removed at
home, and a catheter could be passed into the bladder.
Dr. Physick, from his extensive experience in such
cases, was more sanguine of success in the case, than
were his associates. I can speak, at least, for myself.
The event justified the correctness of his judgment.
The walls of the sinus were broken down by the caus-
tic, w hich was freely employed, while the catheter w^as
steadily retained in the bladder. Strips of adhesive
plaster completed the cure.
CASE XXVII.
An elderly man came under my notice in the surgi-
cal ward, of the Almshouse Hospital, with fistula in
perineo, of seven years duration, attended with a per-
manent stricture of the urethra.
It was a remarkably fine case for testing the efficacy
of appropriate practice, and I felt particularly pleased
in presenting it to the students in attendance. The
indications to be fulfilled were explained, and an oppor-
tunity was afforded for the class to watch the progress
of the case. The caustic was applied freely and fre-
quently to the stricture. No hemorrhage ensued, and I
am inclined to believe, that in old strictures, where the
308 FISTULA IN PERINEO.
sides of the canal are indurated, it is less to be feared
than in recent cases.
In due course of time, the stricture was so far re-
moved that a catheter could be passed forward into the
bladder, in which situation it was retained. The
hardened walls of the fistula were now attacked with
caustic, and soon destroyed. Healthy inflammation
was followed by granulations which filled up the cavity;
the edges were approximated by adhesive strips; cica-
trization ensued, and the cure was eflfected.
Soon after this I had a very similar case in a sailor,
in the venereal ward of the Pennsylvania Hospital.
The fistula had existed for about two years and a half.
The same principles of practice were applied with equal
success.
CHAPTER IV.
TIC DOLOUREUX OF THE URINARY BLADDER.
The experience of the medical profession is greatly
enlarged on that painful and paroxysmal affection of the
nerves, denominated tic doloureux. A few years ago,
this term was almost exclusively applied to a severely
painful affection of the supra and infra orbital nerves;
the disease being always associated in the mind with a
facial locality. More recent investigations have shown
that this affection may exist in various parts of the
body. Under the generic term of neuralgia, we have
a class of diseases which excite much attention at the
present time.
I have known instances of great suffering in the
urinary organs, from this form of disease. Its attacks
are violent, and bear so exact a resemblance to the
paroxysms induced by the presence of calculus in the
bladder, that it is impossible to decide between the two
conditions. In these cases the bladder has been fre-
quently sounded without detecting a stone, and tlie
subsequent progress of the cases induced the belief
that none had existed.
I will briefly state the result of my observations on
this subject.
310 TIC DOLOUREUX OF THE
CASE XXVIII.
Some years ago, a young man came to this city to
{^•:>nsult Dr. Physick; he was affected with the usual
symptoms of a calculus in the bladder.
Dr. Physick did not examine him particularly, but
recommended him to my care, as a proper patient for
the Pennsylvania Hospital, where he might undergo
the operation of lithotomy.
After his admission, on attempting to sound him, he
complained very much of exquisite pain; the parts were
irritable to an unusual degree. No stone was disco-
vered by the examination. My colleagues joined me in
efforts to discover a stone by the usual means, but
without success. The patient suffered from agonizing
pain, which attacked him in frequent paroxysms, and
resembled exactly " fits of the stone." After remaining
for a considerable length of time in the Hospital, and
undergoing a variety of treatment, he was discharged
without being materially benefited, and returned to his
friends. The final issue of the case I never heard.
CASE XXIX.
I was called to visit a middle aged married lady in
this city, who was affected with similar symptoms. She
was naturally of a very delicate constitution, and of a
nervous temperament, and had borne a number of
children.
URINARY BLADDER. 311
She was attacked with this affection of the bladder,
soon after the birth of a child. Her paroxysms of pain
were violent, and resembled exactly the symptoms pro-
duced by stone. She was repeatedly sounded, but no cal-
culus was ever discovered. Aftersuffering intensely from
these paroxysms for several months, her symptoms dis-
appeared, and siie was restored to her usual health.
I am aware that the above cases do not afford con-
clusive evidence of the existence of this disease. Pa-
tients may labour under stone in the bladder, and may
be repeatedly sounded, before it is discovered. Yet the
examination may ultimately prove successful. The cal-
culus may be removed by an operation, and the patient
be finally restored to health. A case of this kind once
occurred in my own practice.
It may also happen that a calculus will become en-
cysted, and in this way the symptoms will disappear,
leaving the impression on the mind of the surgeon, that
the symptoms arose from some other cause.
The question can only be settled by post mortem
examination, and an opportunity has been furnished
me of testing it by this method. I have also the plea-
sure of adding Dr. Physick's testimony to my own, on
this point. In conversation with him some years since
on this subject, he informed me, that he had a gentle-
man under his care, who was affected with clearly
marked symptoms of stone in the bladder. Dr. P.
sounded him frequently without being able to discover
a calculus. The patient finally died. On examination
after death, the bladder was found to be healthy, and no
stone could be found.
After stating this case, the Doctor very emphatically
312 -TIC DOLOUREUX OF THE
said, " The disease is tic doloureux of the bladder." The
definition appeared truly concise and appropriate, and
1 have therefore adopted it.
Since that period a case has fallen under my own
observation, which is very conclusive, and has con-
firmed me in the opinion, that the urinary bladder is the
subject of an extremely painful nervous affection, which
cannot be designated by a term more appropriate than
that which is here adopted.
The following case is a fair example of this disease.
CASE XXX.
Tic Doloureux of the Bladder.
1th mo. 4th, 1822. Died this morning in the Pennsyl-
vania Hospital, R. N., a young woman who has been
an inmate of the institution for several years, during
which time her sufferings have been extreme.
She was afflicted with violent paroxysms of pain,
exactly resembling fits of the stone. She also appeared
to labour under disease of the uterus; had obstinate
amenorrhoea; sometimes a vomiting of blood.
Various expedients were tried for her relief — in fact,
it seemed as if all the medical and surgical skill of the
institution was fairly exhausted on this afflicted, but
patient sufferer! She was placed under the care of phy-
sicians as well as surgeons. Among the palliative reme-
dies in her paroxysms of agony, for so they may be
called, venesection and opiates afforded most relief.
Toward the conclusion of her disease, she had two
URINARY BLADDER. 313
attacks of dysentery, and was happily released from
her troubles in the last attack.
The symptoms of stone in the bladder were so
strongly marked in this case, that the patient was often
sounded. I beheve all the surgeons searched for stone.
I did, repeatedly, and even proposed dilating the ure-
thra, with the sponge-tent, in order to introduce the
finger into the bladder.
To conclude, it may be said, that I never witnessed
a case of more severe and protracted suffering, nor one
in which the symptoms of calculus in the bladder ap-
peared to be more clearly marked. And now, behold
the humiliating evidence of the fallibility of human
judgment, as displayed in the dissection of R. N.
Examination — Post mortem.
The bladder contained no stone, and, Avith the kid-
neys and ureters, presented a perfectly natural appear-
ance! The stomach, liver, lungs, and uterus, all healthy!
The intestines gave some signs of recent disease. The
pancreas was indurated. The muscles red and firm.
There was a considerable amount of fat over the abdo-
men, and on the omentum, although the patient had a
very bloodless aspect.
I was informed by Dr. John Rhea Barton, who was
present at the dissection with Dr. Price and others, that
if he had been called upon, in the dissecting room, to
select a subject whose viscera, generally, presented a
sound and natural appearance after death, he could
scarcely have selected one better adapted to the purpose
than the mortal remains of the deeply afflicted R. N.
40
CHAPTER V.
NEPHRITIS.
The occurrence of nephritic affections, especially in
gouty patients, is familiar to most medical men, and in
the usual course of practice, cases of this kind require
their care.
The seat of this painful affection is primarily in the
kidneys, and from thence is propagated to contiguous
parts. It is caused by the formation of small calculi in
the kidney. Should one of these pass through the ure-
ter into the bladder, a train of most painful symptoms
ensue, often causing great alarm to the patient and his
friends; but seldom being really dangerous.
The disease is generally marked by some peculiari-
ties which enable the practitioner to form a correct
diagnosis, by referring to the anatomical and relative
position of the parts. The pain is referred to the hy-
pogastric region, having an obliquity in its course, cor-
responding to the passage of the ureter from the kid-
ney to the bladder. The testis on the affected side is
frequently retracted and painful. This fact admits of a
ready explanation, when it is recollected, that the ure-
ters and vasa deferentia decussate each other in the
neighbourhood of the part where the former enter the
bladder; hence, irritation and pain in the one, can readily
be propagated to the other. The bladder and urethra,
like continuous hnks in the chain, may experience the
NEPHRITIS. 315
effects of morbid association. The whole nervous sys-
tem may be brought into sympathy. That important
viscus, the stomach, may largely participate, and be-
come involved even in convulsive action, manifested by
severe retchings and vomiting. At the very onset of the
disease, the patient is often instantaneously affected
with great prostration of system, pallor and coldness
of surface, and feebleness of circulation. I have known
syncope to take place at the accession of the attack.
In illustration I will state a case.
CASE XXXI.
A merchant of middle age, a strong, well-built man,
of temperate habits, and possessing considerable firm-
ness of disposition, went to bed in usual health. He
awoke in the night, and felt a disposition to urinate.
He rose from bed for the purpose, and was instantly
seized with such intense pain, that before his w ife could
assist him, he sunk on the floor in a state of syncope.
The alarm of his family can be easily imagined. I saw
him shortly after the attack. His skin was cold; his
pulse very feeble; and his pain was agonizing. Under
proper treatment he speedily recovered.
In the early part of my practice, I once saw this dis-
ease assume an intermittent form. As the case was un-
usual in its character, I will detail it from my note
book.
316 NEPHRITIS.
CASE XXXII.
In the winter of 1806, 1 was called one night from
my bed, to visit J. R., a very respectable man, who
had exchanged the active life of a farmer for the more
easy situation of a citizen. I found him sitting in a
chair before the fire. The pain corresponded with the
course of the ureter. The testis participated. He had
a scalding sensation when he attempted to pass water,
accompanied with tenesmus, nausea, and vomiting. The
case was clearly marked, and depended upon the pas-
satre of a calculus through the ureter. I directed a dose
of calomel and opium, and was about to put other plans
in operation, when, before even taking the medicine,
he said he felt relieved, and that he thought something
had passed from " a small passage into a larger one."
I now obtained from him a clear history of the case.
His first attack was some days before I saw him; it
took place while on a journey from New England to
Philadelphia. It came on about 3 o'clock in the morn-
ing and lasted about two hours. It had recurred regu-
larly every succeeding night since, about the same hour,
and its duration was nearly the same. When the attack
commenced, he always found that he was more easy
in the erect, than in the recumbent posture; and it was
his uniform practice to rise from bed, and set before
the fire until it went off. At the time he sent for me,
the pain was more violent than he had ever before ex-
perienced. This proved to be the last paroxysm.
Nephritic cases are often sudden in their accession,
and speedy in their termination. The patient is in-
NEPHRITIS. • 317
stantly sensible of relief when the calculus falls into the
bladder.
I have met with some cases where the disease as-
sumed a more chronic form, confining the patient to
his room and bed, and attended with inflammation and
fever. It would seem as if the calculus was too large
readily to pass, and considerable time was required be-
fore this could be accomplished.
Treatment.
The course of treatment to be pursued in the acute
form of nephritis is worthy of close consideration. I
feel more inclined to examine this part of the subject,
from the fact, that our practice is these cases is not
uniform and settled. I believe no small injury may
result from associations formed in medical minds, which
must have an important bearing on therapeutics. Thus
pain and inflammation are so intimately associated,
that it seems in some instances impossible to dissever
them. Hence, in all those cases of acute nephritis, one
of the first indications founded upon this conclusion is,
the free use of the lancet. And where inflammation is
to be measured by intensity of pain, it may be free in-
deed. Let us now advert to the circumstances which
may be reasonably supposed to attend an acute attack
of this disease. I^et us take the case of the merchant,
who at the very onset was prostrated by syncope, almost
instantaneously, on the floor of his bed-chamber. What
caused this intense pain? was it not the passage of a
hard and irregular shaped calculus along the extremely
sensitive ureter? Was not the pain suddenly induced
by the operation of a mechanical cause?
That inflammation may follow as a consequence of
»
318 . NEPHRITIS.
contusion, or lesion of parts, is a principle fully un-
derstood. But that it should be coeval with the inflic-
tion of the injury, is utterly at variance with every
principle of surgical pathology. Time must be allowed
for the injured vessels to rally their energies, and
assume those peculiar actions which constitute inflam-
mation.
Does the state of the system, in a case of severe ne-
phritis at its commencement, warrant the conclusion
that the lancet is required? Are pallor and coldness of
surface, with a very feeble state of the circulation sud-
denly induced, to be accepted as evidence of inflamma-
tion? The answer is, no — but the reverse — a state of
prostration. It may be argued, that even if inflamma-
tion does not exist, free bleeding may be useful in order
to prevent it.
To discuss this question, would at present be out of
place; were it entered upon, I think it might be shown
by a reference to practical facts, that the doctrine of
free bleeding as a prophylactic for inflammation, is far
more vulnerable than is imagined. I regard it as un-
sound. Perhaps at a proper time, an opportunity may
be offered for further illustration.
It may be urged that patients speedily recover after
free bleeding. It may be replied with equal truth, that
they speedily recover without it. The violent case of
the merchant was a striking instance in point — he did
not lose one drop of blood.
I have long since established it as a medical axiom,
when a practitioner can achieve his object by a resort
to safe, yet efficient remedies, without drawing largely
on the constitutional energies of his patient, it is wise
to pursue the former course, and reserve the latter for
NEPHRITIS. 319
those emergencies which do arise, where minor consi-
derations must yield to the one all-absorbing indication,
the rescue of the patient from the grasp of a fatal dis-
ease. These observations may be regarded as a digres-
sion; but they are felt to be due to the profession, inas-
much as physicians, as well as surgeons, are deeply inte-
rested in the disease now under consideration.
The primary indications of treatment in acute ne-
phritis, are the following: — x\llay pain and irritation by
the use of opiates, having reference at the same time
to the state of the bowels. If they should be confined,
it is advisable to combine some purgative with the
opiate. I often combine two grains of opium with ten
or twelve grains of calomel made into pills. Sometimes
if the symptoms are very urgent, I have given three
grains of opium with the calomel. In many cases I find
a dose of castor oil with laudanum, to answer quite as
well as the calomel. Should the stomach reject medi-
cine, I resort to anodyne injections, preceded by laxa-
tive enemata, if there is reason to suppose the rec-
tum contains feces. When we consider the contiguity
of the rectum to the urinary bladder, it is easy to
understand how a soothing impression made on the
former, will be speedily propagated to the latter. Hence
an anodyne injection sometimes acts like a charm.
Could it be readily obtained, it might often supersede
the exhibition of remedies by the mouth.
Another indication consists in restoring heat and
action to the surface, and particularly the lower extre-
mities. Thus sinapisms maybe applied advantageously.
Immersion of the feet and legs in warm, or rather hot
water, to which either mustard or coarse salt is added.
Spirituous fomentations to the abdomen are frequently
320 NEPHRITIS.
useful. If relief is not procured, a warm bath would be
clearly indicated. These means seldom fail to miti-
gate the violence of the disease. The calculus passes
into the bladder, and full relief is obtained. When the
stomach will bear mild demulcent drinks, they should
be freely used. Sometimes before a resolution of the
paroxysm, reaction takes place, and fever ensues; then
depletory measures are indicated. In vigorous subjects
general and topical bleeding are required. In subjects
of a more delicate and feeble character, cupping or
leeching about the lumbar vertebrae, aided by laxatives,
warm bath, and injections, may prove sufficient. Some-
times I have directed large quantities of tepid flaxseed-
tea to be introduced into the bowels, to act upon the
principle of a warm bath internally applied. Anodyne
injections, when the pain is severe, are particulary pro-
per.
Among the internal remedies, the spirits of turpen-
tine may be noticed. One of my medical friends who
has been severely afflicted with nephritis, has great con-
fidence in the remedy. When he feels the least threat-
ening of an attack, such as uneasiness and slight pain
about his kidneys, he will alight from his carriage before
the shop of any apothecary, and take twelve drops of
spirits of turpentine on loaf sugar, with decided relief.
Patients liable to nephritis, often consult their phy-
sicians relative to prophylactic remedies. To enter
fully into this subject would lead beyond my pre-
scribed limits. I would briefly remark, that in some
instances the uva ursi, the extra soda water, and the
Saratoga water, appear to have produced a very salu-
tary effect. In this city, the scabious tea is a popular
remedy. It has derived much of its reputation from
NEPHRITIS. 321
a valuable old citizen long since deceased, ^^ho was in
extensive business as a biscuit baker. He was severely
afflicted with the disease, and had derived such relief
from the scabious, that at the proper season to gather
the plant, he was in the practice of going out with his
work-people, and his horse and cart, in order to collect
it in the fields round the city. Having obtained a large
supply, he always kept it for gratuitous distribution,
humanely desiring to confer that relief on others, which
he believed he had himself received from the scabious.
It has been stated, that nephritic affections, depend-
ing on calculi formed in the kidney, although very pain-
ful, are seldom of a dangerous character.
It now remains for us to consider another morbid
condition of this organ, by which its structure is gra-
dually altered, and the death of the patient is the re-
sult.
The following cases illustrate this singular form of
disease.
CASE XXXIII.
Irritable Bladder and Urethra — Disorganization of the
Kidney — Death .
4th mo. 10th, 1821. B. R., a respectable merchant,
about sixty years of age, had long been subject to
gout, and had lately been affected with much depression
41
332 NEPHRITIS
of mind, arising from a failure in his business. For
more than a year preceding his death, he had suffered
grievously from an affection of the urinary organs. He
was obliged to make frequent efforts to pass small
quantities of urine, during the day and night. His ure-
thra was extremely irritable, and the most careful at-
tempts to introduce the catheter caused him great pain.
I at one time suspected the presence of a calculus, but
could discover nothing by sounding. Sometimes he
had retention of urine requiring the use of the ca-
theter.
Under these circumstances, various means of relief
were tried without any salutary effect. His strength
gradually failed, his complexion assumed a sallow hue,
and his whole aspect exhibited evidences of great
bodily suffering. It was also evident, that a sensitive
and upright mind participated largely in his afflictions.
For several weeks before his death, he was affected
with severe muscular spasms, affecting both the upper
and lower extremities. There was also an evident
failure in his mental faculties a short time before his
death.
Dissection,
The body was examined by my friend Dr. Harlan.
The internal surface of the bladder was interspersed
with dark spots, curiously intersected by whitish bands,
which did not rise above the surface of the mucous
membrane. At the neck of the bladder around the
opening of the urethra, there was a red spot about the
size of a quarter of a dollar.
The kidneys were unusually small. The infundibula
NEPHRITIS. 323
of the left kidney were very large, and the pelvis of the
right was very much distended, giving the idea of a
stricture in the ureter, and a regurgitation of urine
into the pelvis; though no stricture was discovered.
The prostate gland presented a healthy appearance.
From the symptoms, I had expected to find great
thickening of the mucous and muscular coats of the
bladder.
I have extracted from my notes the following case,
which, in some respects, bears a strong resemblance to
the preceding.
CASE XXXIV.
In the autumn of 1809, 1 was consulted by an elderly
and highly respectable man, from Lancaster county, who
came to this city seeking relief from a very painful dis-
ease. He had been for a long time affected with an
irritable bladder, and an exquisitely morbid sensibility
of the urethra, such as I had never seen surpassed. In
his attempts to pass urine, which were frequent, he com-
plained of severe pain and scalding in the canal, parti-
cularly towards the arch of the pubis. The pain ex-
tended from the point of the penis inwards, and ho
experienced slight uneasiness about the neck of the
bladder. He once had a stricture, but this had been
cured.
I sounded him for stone, examined the prostate, but
could find nothing which satisfactorily explained the
symptoms. He was under my care for many weeks,
and a variety of remedie? were tried. His complaint
324 NEPHRITIS.
was palliated, but he was not permanently benefitted.
He used opium, hyosciamus, stramonium, colchicum,
*kc., also, emollient injections into the bladder. He re-
turned home for a while, and subsequently came back
to the city, and placed himself under the care of seve-
ral different practitioners. I was called in consultation
with one of them, but, as on other occasions, no treat-
ment successfully reached the case. He returned home,
and died.
I have been informed by one of his friends, that he
was examined after death, and that one of his kidneys
"was nearly wasted away." His friend was not a
medical man, and of course I could not obtain the pre-
cise information which I desired. The symptoms bore
a strong resemblance to the preceding case, and I pre-
sume depended on the same cause.
In reflecting on these cases, which, so far as my ob-
servation extends, are of an unusual character, I have
arrived at the conclusion; that if I should again meet
with a case of extreme sensitiveness in the bladder and
urethra, which could not be referred to any obvious
cause, as an enlarged state of the prostate, stricture of
the urethra, &c., and which differed from tic doloureux
of the bladder, in the permanency of the pain, and the
absence of paroxysms, I should refer it to some organic
lesion of one or both kidneys, depending on a gouty
diathesis.
Whether this disease could be eradicated by any
method of treatment, pursued in the early stage, I am
altogether unable to determine from experience. Per-
haps the application of setons, or perpetual blisters on
NEPHRITIS. 325
each side of the spine, or even in a remote situation,
might exercise a favourable influence, by causing a
weaker part in the vicinity of the affected organ, and
thus acting on the principle of metastasis.
The remedies adapted to the treatment of gout,
when it occurs in other parts of the body, might also
deserve a trial.
CONCLUSIOxN.
My observations on Strangulated Hernia, and some
of the Diseases of the Urinary Organs, are now closed.
It will be perceived, that the volume is plain and prac-
tical in its character. It is said, every man who thinks
theorises. Perhaps, in one sense, this may be true. It
is very important, however, that theories should be
based on a solid foundation. I hold myself still to be
a student in the school of practical observation, and am
frequently picking up useful knowledge in passing
along, and am gaining much information from others.
I have found out too, that it is an easy matter for an
ingenious man to tell what he thinks, and sometimes
very useful hints are to be obtained from the thoughts
of others. Still it must be acknowledged that more is
to be learned when a man, whose accuracy is to be
depended on tells what he really knows. In common
with the elder members of the profession, the writer
has seen beautiful theories erected — the builder has ad-
mired the work of his own hands — a few simple facts
have undermined the foundation — the edifice has tot-
tered, and fallen into ruins. It is my earnest desire to
avoid every just cause for the suspicion of vanity and
egotism. In putting forth this book, the writer could
not gain his own consent to send it out, w'ith abun-
dance of apologies for its numerous imperfections,
while at the same time he did not believe such to be the
fact.
CONCLUSION.
327
Still he is fully aware that an author may view his
first book, a little like a parent views an only child.
He may see beauties where a disinterested person
could not discover any thing uncommon. What is
more important, there rnay be defects and blemishes,
which strike the eye of a stranger very forcibly, that
the parent, having the child constantly before him, is
scarcely sensible of their existence. My object is the
diffusion of medical information, in the hope that it
may prove useful to others. Could the reverse be sup-
posed, or that any one part of the work might lead
to unsound conclusions, or incorrect practice, most
sincerely would the author regret that any of his ma-
nuscripts ever found their way into the hands of the
printer. So far, then, from shrinking from criticism in the
spirit of candour and kindness, it is rather invited, never
expecting to be too old to learn, and always desiring to
have my errors corrected, and improvements placed in
their stead.
It is one of the consolations of my life, to look around
among an extensive acquaintance with the medical pro-
fession, some of them older, but a very large majority
younger than myself, and to feel that they are my bre-
thren. Although we may honestly differ in some of our
medical views, yet I can rejoice in extending the hand
of friendship to a numerous body of fellow labourers in
a profession which has for its object the mitigation of
human misery, and the preservation of human life. It
is a profession which is high, and ought to be dignified
and honourable; but neither its dignity, nor its honour,
can depend upon high sounding titles, nor upon name.
It must be bottomed on solid attainments in medical
science, and separated from merely sordid views. That
328 CONCLUSION.
it is still associated with many of the imperfections,
which are incident to humanity, is freely confessed,
while it may not be arrogant to believe, that the nume-
rous streams which flow forth from the fountain of
medical science, are still extending their blessings over
the land, carrying with them healing virtue and conso-
lation to the afflicted and destitute.
There is now rising around us a large body of ta-
lented and enterprising young men, who have most in-
dustriously engaged in the arduous and responsible
duties of medical life. I view with deep interest their
rising usefulness, and heartily wish them good speed.
To the elder members of the profession, and to some
in an especial manner, my feelings are of no ordinary
character. As the circle narrows, our attachments in-
crease. How many have we followed to the grave.
The very hands that were so frequently stretched forth
to parry the arrow of the archer, have at last fallen
powerless from his wound. Some of us have stood
side by side in times of public calamity, sharing a com-
mon danger, while some of our brethren have fallen in
the conflict. The pestilence which walketh in dark-
ness, and wasteth at noon day, we have seen to come
up into the windows, and to cut off the young men from
our streets. We still remain — we still join in daily
professional intercourse, and with entire confidence
in each other, share mutual responsibility. How can
it be other then, that the humble hope should be in-
duljied, that when we also shall fall before the arrow of
the destroyer, the spirits that are now congenial, shall
still be permitted to mingle together, and enter upon a
more exalted sphere of existence, where hope will be
lost in fruition.
FINIS.
EXPLANATION OF THE PLATES.
Plate I.
View of the interior of the lower part of a bladder,
with a diseased prostate gland, to show the effect of
an enlargement of the third lobe of that gland.
a, a. Section of the parietes of the lower part of the
bladder, posteriorly.
b, i, b, b. The diseased prostate gland greatly de-
veloped.
c, The third lobe of the gland enlarged and project-
ing into the cervix of the bladder, where it overhangs
the internal orifice of the urethra, like a valve.
d, The membranous portion of the urethra.
e, e. Part of a catheter introduced through the ure-
thra into the bladder, lifting up the third lobe of the
prostate gland in its passage.
J\f. The vesical extremities of the ureters.
g, g. The seminal ducts.
Plate IL
Interior view of the bladder, with enormous deve-
lopcment of the third lobe of the prostate gland.
a, a. Section of the parietes of the bladder.
h, b, b. Enlarged prostate gland.
c. Third lobe of the gland projecting far into the
bladder.
42
330 EXPLANATION OF THE PLATES.
Plate III.
Section and interior view of the fundus of a bladder
taken from a subject with enlarged prostate gland; show-
ing the columns of the mucous coat, caused by long-
continued dysuria, and resembling the muscular columns
of the heart.
Plate IV.
Fig. 1. A canula for guiding a catheter into the
bladder, in cases of enlarged prostate gland.
«. The eye of the instrument.
b. Two marginal notches corresponding exactly with
the eye of the instrument.
Fig. 2. The extremity of the same instrument, with
the catheter introduced; to show the obliquity of the
extremity of the latter, on passing out at the eye.
a. The end of the catheter.
Fig. 3. A view of Dr. Parrish's favourite bistoury
for the operation on strangulated hernia.
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