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GERDY on the other hand attempted closure of the canal by crowding and stitching the integuments into it and removing the cuticle by caustic alkalies. This was called “invagination by the integuments," and is the basis of several recent and rather popular operations.
BELMAS' operation consisted in crowding a pouch or roll of goldbeater's skin into the upper part of the sac, and afterwards into the neck of the sac near the ring, thus attempting the closure by causing inflammation and adhesion.
GRAEFE made an incision at the external ring, cut off the neck of the sac, and crowded a roll of lint into the inguinal canal as far as the internal ring, with the expectation of causing inflammation and closure by adhesion. The introduction of a seton into the neck of the sac for the purpose of closing it, is essentially the same proceeding. This method, rough as it was, effected some
The operation of plugging the inguinal canal by leaving the omentum in it, after its protruding portion had been cut off, in the operation for strangulated hernia, was a better and more successful proceeding, though similar in design. Cooper and Velpeau succeeded by this method.
Bonnet used pins to bring about the requisite inflammation. The pins were introduced beneath the skin and near the ring, one above and the other below the neck of the sac, in such a manner that the neck could be compressed between them, by bending one over the other, and thus excite inflammation in from six to twelve days.
Mayor used needles instead of pins, thus carrying a ligature around the neck of the sac and tying it over a piece of sponge. The ligature could be tightened from time to time and allowed to remain long enough to produce the desired effect.
VELPEAU scarified the inguinal canal, a proceeding not devoid of danger from hemorrhage, and Guerin scarified the neck of the sac by a subcutaneous method. Similar to this in idea was the method by acupuncture of the neck of the sac near the external ring, advocated by Malgaine, and practiced considerably in this country and in Europe.
VELPEAU and Dr. Pancoast practiced injection of iodine or tincture of cantharides, in or near the neck of the sac. The former opened the neck and injected the iodine into it. The latter introduced it subcutaneously by means of a small syringe. It is difficult to hit the sac by subcutaneous puncture.
It will be seen that the object aimed at in all the operations related above was closure or contraction of the neck of the hernial sac. Even Velpeau's proceeding of scarifying the inguinal canal, seems to have no further design than to close the sac in the canal. These operations failed in most cases to bring about a closure of sufficient resisting power to prevent the descent of the intestine, and for the reason as stated hy Lawrence that “something more is required; we want a remedy that should contract the tendinous opening; for while that remains preternaturally large a new protrusion is a highly probable occurrence.”
Admitting that the operations accomplish all they are designed to do, viz: close completely the neck of the sac, they will not contract the tendinous opening, and hence a new sac may be formed even if the closure of the old sac is perfect, and thus the intestine protrude anew. In order that the case then shall be truly radical, some measure should be devised to close or contract the ring itself. This has been attempted. First, scarifying the ring, an old operation, but not effectual, and not free from danger of wounding the epigastric artery. Second, closing the ring, as practiced by Dr. Thomas Wood of Cincinnati, by means of sutures. The object is to close or constrict the external ring by a tendinous growth, for he remarks "tendons when wounded will unite again by a formation similar to their original structure." Theoretically this operation has an advantage over all others, but it does not seem to have been much employed, and the presumption is, that it has been found no more successful than many other methods.
All the methods described have been successful in some cases, some in a greater proportion than others. The two operations most popular at this time seem to be Wützer's and Mr. John Wood's. The first is essentially the old method of Gerdy, by invagination, the difference consisting in means devised to retain the invaginated integuments in the ring, viz: by means of an instrument. The second is essentially an attempt to close or contract the inguinal canal by means of subcutaneous suture or ligature. It is essentially the old idea of ligature or suture revived, but so applied as to obviate some of the objections to the old method, especially the destruction of the testicle. Invagination of the spermatic fascia and the hernial sac is also a feature of the operation. It is, therefore, a revival and combination of the old method by suture, and the method of Petit, viz: of crowding the sac into itself. Moreover, the ligatures are so applied as to lessen the tendinous opening. It therefore aims to effect a cure by combining the several methods; of dealing with the sac; of invaginating tissue into the inguinal canal; and of contracting the tendinous opening.
The first method, Wützer's, is theoretically a method of elosing the external ring. Its object is to place a firm substance in the ring and fix it there by adhesion. The operation is very likely to fail, the adhesion of the invaginated portion not being so firm but that the intestine will push down. It fails because the scrotum by its weight draws out the invaginated portion, because it enlarges the external ring by crowding the integument in, and because adhesion does not take place at the posterior part of the canal, thus giving the intestine a chance to escape behind it.
The method of Mr. John Wood he claims has succeeded in many cases; patients having been kept under observation long enough to establish the fact of cure. The cases cured are in the proportion of seventy per cent. to the operations, a ratio of success much greater than has been attained by any other method. It has also this additional claim to attention, that it is a safe operation. Mr. Wood reports one death in one hundred and fifty operated upon by him. It is necessary to wait more than a year in an adult, and especially one at all advanced in years before deciding that the cure is radical. In children and youth the necessity for waiting for time to pass is less, and the probabilities of radical cure greater as time passes and the protrusion does not reappear.
The method by injection was once said to fail altogether. But time has shown that some cases treated by that method were permanently cured, and it will succeed in a certain proportion, the younger the subject the better the chances, which in fact, may be said of all methods. The method is more likely to succeed if the sac is scarified by a tenotomy knife before the iodine is injected, thus in a measure reviving Guerin's method of dealing with the
neck of the sac by a subcutaneous scarification, and adding injection to it.
For an infirmity so common-about eight per cent. of the human family being afflicted with it—so inconvenient, and in some instances so dangerous, it is to be hoped some effectual remedy will soon be discovered, since all methods thus far practiced fail in a number of cases. We may express the hope that the new method promised by a surgeon of Philadelphia-Dr. D. Hayes Agnewmay prove that effectual one, which all surgeons have been anxious to find. Up to this time Wood's operation seems to have afforded most relief and is in most repute.
ART. II-Abstract of Proceedings of the Buffalo Medical Association.
TUESDAY EVENING, July 2d, 1867. The meeting was called to order by the President at the usual hour. Members present—Drs. Eastman, Little, Smith, Kamerling, Rochester, Strong, Congar, Wetmore, Lothrop, Gay and Johnson.
Reading the minutes of the last meeting was, by vote, dispensed with.
Drs. G. E. Mackay and M. W. Potter were proposed for membership
DR. ROCHESTER reported the following case:
On the 26th of May a gentleman was attacked with what appeared to be the passage of a renal calculus. He had been treated by Dr. Rochester a year before, for what seemed to be that disorder. He was first seen by Dr. Abbott, Dr. Rochester being professionally occupied elsewhere. There was severe pain in the right lumbar region, stranguary, retraction of right testis and vomiting, with marked chill, followed by febrile movement; tongue coated, bowels costive, abdomen tender and slightly tympanitic, urine scanty, highly colored, with acid reaction and copious lateritious deposit. Dr. Abbott injected half a grain of morphine with hypodermic syringe, and directed hot fomentations and diluent drinks. The patient was much relieved and spent a tolerably good night. He was first seen by Dr. Rochester at 11 A. M. May 27th, who confirmed Dr. Abbott's diagnosis, and essentially continued his treatment. In the evening, however, he found that the indi
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cations were rather those of localized peritonitis with disease of the vermiform appendix. He had before met with one case of this disorder which simulated renal calculus passage. The case progressed rather favorably than otherwise until the evening of the 31st. At 4 P. M. on that day the patient was quite comfortable. At 71 P. M. Dr. Rochester found Dr. Gay in temporary attendance. Comatose symptoms had suddenly manifested themselves about 6 P. M., and so strongly did they resemble narcotism that Dr. Gay supposed an overdose of morphine had been accidentally taken. The pupils were contracted to a point. The respiration was stertorous. The nails and lips were livid. The surface was bedewed with moisture, and the extremities were cold. The patient could be roused by slapping and by shaking, but immediately lapsed into insensibility. For the last twenty-four hours onefourth of a grain of morphine and two grains of quinine had been given every four hours, alternately, with four drops of Norwood's tincture of veratrum viride, and twelve hours previously half a grain of morphine had been hypodermically applied. It was ascertained that there had been no error in the preparation or administration of the medicine. There was one very strong indication that the coma was not from opium. The respiration was forty per minute. Dr. Rochester expressed the conviction that the coma proceeded from exhaustion, induced by shock caused by gangrene and perforation of the vermiform appendix. Death took place June 1st, at 7 A. M. Post mortem examination was made by Dr. Abbott, at 4 P. M. The appendix (preparation exhibited) was found to be hypertrophied, gangrenous, and perforated by a large orifice half an inch from its cæcal attachment. The foreign body had escaped into the abdominal cavity, and was not discovered. The usual evidences of peritonitis were present.
Dr. Rochester said that there were several noteworthy peculiarities to which he would call attention. First; the outset of the attack, simulating, from sympathetic irritation, the passage of a renal calculus. Second; the age of the patient, forty-nine years, as this is mostly a disorder of young people. Third; the deep coma, at the last, instead of the usual jactitation and nervous irritability.This was the eleventh case that Dr. Rochester had encountered in a practice of about twenty years; he had, perhaps, had more than