If the changes had been more of a structural character and confined more to the medulla oblongata the respiratory and the vaso-motor centres of the cord would be more generally affected, and life would have oftener been more at stake. As it was these centres were not interfered with, though the disease had one of its principle centres of attack here.

The structural changes in the brain and cord were slight, for there are no symptoms to-day that point to any degeneration of these nervous centres.

It shows, too, the good use of the iodides in absorbing the inflammatory matters that were so frequently thrown out, causing compression.

SOME OF THE COMPLICATIONS OF STRANGULATED HERNIA.*

I

BY R. HARVEY REED, M. D.

SHALL not presume on the intelligence of the members of this Association by unnecessarily occupying your time in giving either the history, anatomy or even a description of this comparatively common operation, which is doubtless, alike familiar to us all.

There are few cities in America at this time that have not one or more surgeons who can show a record of successful operations for strangulated hernia, and who are perfectly familiar with every step in this important operation.

Hence I shall confine myself to a report of some of these complications, which may arise in the path of any surgeon who seeks to relieve his patients of this dreaded malady by operative interference, as illustrated by a few cases that have come under my notice.

C. S, æt. 30, a vigorous, strong, muscular, stonemason. I was called in counsel with a physician of one of our neighboring towns on April 16th, 1885, and found on inquiry that about nine years previous to this attack a hydrocele had made its appearance on the right side, which had subsequently been tapped, and temporarily relieved.

About the time the hydrocele made its appearance the right testicle was observed to be enlarging, which continued for some time after, until it became more than twice its natural size, and remained so from that time on. On examination it was found to be hard and of a fibrous character; was not painful; was adherent to the surrounding structures, and was to a great extent immovable, either voluntary or otherwise.

On further examination he was found to have a large hydrocele on the right side, and a strangulated complete inguinal hernia.

Neither the patient nor the attending physician had

*A paper read before the Surgical Section of the American Medical Association at its 37th annual session, held at St. Louis, Mo., May 4th, 5th, 6th, and 7th, 1886.

any knowledge of the existence of a hernia prior to the present illness, nor in fact then until he commenced stercoraceous vomiting some ten or twelve hours before.

After a fruitless attempt at reducing the hernia, I tapped the hydrocele and drew off over a pint of water, after which the hernia was reduced by taxis, and dressed with a spica of the groin, and the patient given an anodyne, and quiet in the recumbent position enjoined.

Very much to our surprise, we were informed the next day the patient was no better, but on the contrary was still vomiting fecal matter and gradually getting worse, owing to which, they desired me to come and see him.

Being so engaged as to make such a visit impossible at that time, I requested my friend Dr. J. Harvey Craig to go in my place, who found the hernia down, which he returned without much trouble and dressed as before.

The third day the same message was repeated with emphasis, and we were again requested to visit him.

By this time the case had become unusually interesting, and in company with Dr. J. W., and J. Harvey Craig we again visited the patient, and held a general counsel with his attending physician, only to find the same apparent condition as had previously been existing, and again reduced the hernia and advised the attending physician to be vigilant in keeping it reduced by carefully watching the compress and bandages, in the belief that that would give him the desired relief; but this was not the case, for the vomiting did not abate in the least, and on the fourth day the same message was repeated as before. Accompanied by Drs. Craig, Sr. and Jr., we again visited the patient and found the hernia protruding as before, which, owing to his incessant vomiting and straining, made it almost impossible to keep reduced.

After a careful examination and general counsel, it was agreed to by all, that some concealed difficulty of the bowel existed, and that an operation to discover and relieve it was in order, and the only apparent method which would give him a longer lease of life.

Dr. J. W. Craig, being the senior surgeon, proceeded with the operation, while the rest of us acted in the capacity of assistants.

The incision was made along the line of the inguinal canal, from Poupart's ligament to the intestinal ring, and the parts carefully dissected up until the inguinal canal was exposed, but no strangulation found.

The finger could easily be passed into the abdominal cavity through the internal ring, but no constriction. could be discovered. The opening was enlarged sufficiently to admit of a careful examination of the condition of the small intestines, which were found normal.

On further examination, however, it was discovered that the ascending colon had been dragged down further than usual, until the lower end of the vermiform appendix had escaped through the opening of the femoral

consisted: first, in thoroughly cleansing it with iodized water, after which I closed the wound with a fine silk suture, and after carefully replaciog the bowel in the abdominal cavity, closed the external wound with interrupted sutures and allowed it to heal by granulation; meanwhile keeping it cleansed with iodized water, and drained, and enforcing quiet and a rigid diet on the part of the patient.

Notwithstanding all this, he made a rapid and complete recovery without any further bad symptoms.

In this case the only complication arising came on during convalescensce, and consisted chiefly in the rupture of the bowel, which was the result of carelessness on the part of himself and friends, with wilful disobedience of the surgeon's commands.

Similar complications may occur in a country practice where the surgeon has not the advantages of hospital nurses, and often the inconvenience of poverty to contend with, combined with ignorant and careless nurses, who either fail to realize or neglect to heed the surgeon's advice.

While the operation for ordinary strangulated hernia is comparatively a common one, and when performed under ordinary circumstances, before it is too late, the prognosis may be considered a favorable one, yet the chance of complications is always possible, and when they do occur the urgencies of the moment are always imperative and more or less perplexing to the surgeon.

In view of these facts I have ventured to present this association the above report, in the hope that it might add a possible ray of light on some of the complications of the many which may occur in strangulated hernia.

IN

Mansfield, O., April 28, 1886.

SOME POINTS CONCERNING HERNIA.*

BY JOHN KELLY, M. D.

N this paper the term hernia is used in a somewhat re stricted sense, meaning the protrusion of any of the contents of the abdominal cavity through an opening in the anterior walls of that cavity.

It is of frequent occurrence (oftener in men than in women, and oftener in workers than in other classes, some say because there are more of them), and the causes are many. One in three is said to be due to heredity. Normal weak points, such as the opening, for instance, near the umbilicus, the external, internal, crural and obturator rings; abnormal conditions, such as lax

ity of mesenteric folds and parietal layer of peritoneum, sex, occupation, failure in closure of the sheath of peritoneum that descends with the testicle (said to be the most common on the right side), muscular exertions, injury, etc., are among the causes.

* A paper read before the Detroit Academy of Medicine.

The varieties of hernia are named from the opening through which they protrude, from the contents of the sac, and also in certain cases from the conditions of certain parts, for it is to these conditions that the terms infantile and congenital refer rather than to the period of life at which the disease is contracted.

There is no congenital hernia in the female, at least it cannot be distinguished. In the male, if scrotal, it is known by the position of the testis, this being imbedded in the protruding viscus higher up than the bottom of the sac. In this sort it is sometimes difficult to locate the testis.

There is very little difference between hernia in a female and that in a male, except that caused by the difference in the parts involved, that is the structures it follows down and its lodgment.

In most cases its development is slow; the person, although noticing that something is wrong, pays no heed to it till it interferes with his or her mode of life.

I know of a man who was ruptured while in the army, and through carelessness and pride he went on doing his duty, and never reported to the doctor. For that reason he cannot now, though being much injured for his work, being a cutter in glass works, get a pension as the surgeon of his regiment cannot say that he contracted the disease while in the army.

The tumor consists of the sac, if as is usual there is a sac, its contents, and the soft parts over it. Sometimes the sac is the same as that in which the testis is lodged, sometimes another process of peritoneum, and sometimes an inner sac is formed of a fold of omentum. The contents of the sac may be simply omentum, but usually there is some portion of intestine. Eighty-four in every 100 cases are inguinal. These may be oblique, coming through the whole length of the inguinal canal, internal oblique through the lower part of the canal; or direct, coming directly through the external ring, having forced a way through or between the structures beneath the ring.

As to the coverings of hernia, like all things else about the complaint, they are so minutely described as to be confounding. If every shred of tissue involved in other diseases, were so much described and had as many different names as in hernia, to retain in mind sufficient anatomy for the surgeon's purpose would, to ordinary heads, be a hopeless task. All structures that normally were between the skin near the lodgment of the viscus and its normal position form the covering.

They are described in layers, but it is not likely that

they could be found as described in an operation upon any hernia, unless it were very recent or one prepared on a cadaver for illustration in the teaching of anatomy. Degenerative change, new formations, adhesions, etc., take place very soon. The tissues are much thickened or much thinned, according to the amount of irritation and pressure.

The symptoms of hernia are sometimes unmistakable and sometimes obscure. Notably obscure are those of the obturator hernia, which is, fortunately, rare. The impulse on the patient's coughing is pretty sure, though it may happen that the viscus is enclosed in omentum and attached by adhesive bands, so that this symptom will be wanting, and this will be so whether the patient stand or lie down. It has occurred that a doctor, mistaking a hernia for another sort of tumor, prescribed an absorbing liniment and friction. The case proved fatal, and it was said that the treatment made it so.

Many have this disease for some time, and either do not know it, or, through their dislike of having it known, do not seek aid till it is well advanced; and, strange to say, there are some who fancy they have the disease when they have not. This does not, as is the case in some diseases, occur as far as I know, often enough to give a name to the whim, but I know a man who wears a truss, though he has been assured by excellent authority that he has no hernia, and there are no indications that he is going to have one.

Many times a physician is not consulted in a case of hernia till there are symptoms of strangulation, the patient having for a time attempted to control the diffi ulty himself, wearing useless trusses, etc., causing irritation and an accumulation of new tissue and adhesions round the neck of the sac. Symptoms of strangulation are about the same in all kinds, but are milder in degree in an epiplocele.

In inflammation of the hernial sac we also have the same symptoms, though the contents of the sac may have returned to the abdominal cavity. Treatment for strangulation is taxis or herniotomy. Taxis with patient under an anestheticis generally successful, preventing destruction of the part and consequent peritonitis.

An irreducible hernia is sometimes made reducible by local applications—some say hot, but more say cold— and mild cathartics. If permanently irreducible, support is all that is left to do, except to advise exceeding great care on the part of the patient to avoid injury.

In reducible hernia, especially inguinal, the treatment is palliative (which sometimes brings about a permanent cure), or radical. All of the older methods for the radical cure of reducible inguinal hernia are said to be useless, some of them ludicrous (such as the r yal stitch and blocking the opening with the testis), and some of them barbarous (such as the cautery and castration), so that in some countries it was made a capital crime to do the operation. The object was to cause sufficient inflammatory action to bring about union between the parts, but the result was more often suppuration and much danger to life. Even the latest and most approved methods are not in much favor, and are only advised when a hernia is troublesome and cannot be controlled with a truss. Pressure seems to be the chief element in the treatment, and the best form of applying

it is in the truss. This, when circumstances are favorable, will bring about a permanent cure without danger to life. Excellence in an appliance is that it holds the hernia with the least possible inconvenience and in no way injures the constituents of the cord.

Most persons who have had a hernia for any length of time have had some experience with frauds, and have paid out more or less money for useless appliances and useless attendance. The whimsical element that is in so many patients with this disease accounts for this. I assisted a doctor to adjust some trusses once, and during the time I was in the office, an old man came in. He would not say whether he had a rupture or not. The doctor wished to examine him, but he resented that, and said he guessed he knew enough to examine himself. He bought an arrangement that he thought would be of use to him. I learned afterward that he came again, and was fitted with a satisfactory truss. He said the thing he bought was for the wrong side, and would have been of no use had it been for the right side.

I saw a case some time ago. The immediate trouble was urinary, but I think it was caused by a hernia. The patient was a man about 77 years old, of rugged ancestry and an excellent constitution. Had been ruptured by heavy lifting in early manhood. The tumor is now very large; has not worn a truss for 9 years. I had heard of him for some years as having difficulty with his kidneys. He had been taken with an attack about three or four weeks before, from which he had recovered but very little, and now the trouble seemed aggravated, but he had some muscular twitching and was excessively nervous, shaking so that he could not hold a cup to drink from. The bladder was much distended and the hernia was also very tense and seemed inflamed. I passed a hard rubber catheter that had been used when he was first taken and was surprised at the motion it took just before entering the bladder, it was as if there was a crook in the urethra turning toward the hernia. After the urine was drawn he was easy and was some better for a day or two, but could not eat and continued very nervous. The urine was acid in reaction, contained pus, a slight amount of albumen due to the pus, I think, a lot of amorphous phosphates and much ropy mucus. He said that he passed gas through the urethra. This did. not occur at any time when I observed him, and he was angry with me once when I said I was not sure that it did occur. I think that appearance was caused by gases passing from the hernial sac into the abdominal cavity. This happened with a good deal of noise whenever he passed urine causing interruption and spluttering of the

stream.

I gave him tonics and mild diuretics, and he lived. mostly on milk diet. I was disappointed that the urine continued to be fetid in spite of my treatment, but when I washed the bladder out the urine cleared up and the man soon grew better. I found that the bladder could