repeated efforts when taxis has been unsuccessful under anæsthesia. As a rule, we are correct in saying that taxis is positively contraindicated if the strangulation has existed for more than twenty-four hours.

If manipulative methods succeed in reducing the strangulated hernia the patient cannot be considered out of danger. If there is reason to believe from the general symptoms that the strangulation has not been relieved, operation should be resorted to at once even if the hernia has been reduced. The reduction of a strangulated hernia en masse is an uncommon occurrence, but it is of sufficient importance to warrant careful consideration.

When operation has been decided upon for the relief of a strangulated hernia there are certain indications that are. always to be met, and certain procedures that should or should not be done, according to the condition of the patient and the contents of the hernia. If operation is done early and the contents of the hernia are in good condition, and the patient's general state is not serious, general anesthesia can be resorted to and the radical operation carried out in the same manner as would be done if strangulation was not present. The great majority of patients, however, who are subjected to operative treatment for strangulated hernia do not present features so favorable as these just stated. General anæsthesia should be avoided in all of those cases in which the patient's physical health is not good; in which profuse. vomiting is present, and in which inflammatory reaction in the hernia has occurred. Local or spinal anesthesia should then be resorted to.

cases.

If an operation is done the relief of the constriction is the first indication. This must be exposed and severed in all The remaining procedures that may or may not be called for are best considered in relation to their importance. If the intestine is so involved that it is impossible to determine positively that it will regain its vitality, the constriction should be divided and the contents of the hernia left in posi

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SHELDON: PERITON EUM AND SMALL INTESTINES.

199

tion. Moist, aseptic compresses should be placed upon the intestines and left three or four hours, or even over night, as has been done by Erdmann. If the loop or intestine regains its vitality it can be returned to the abdominal cavity and the radical operation carried out. In these cases the relief of the constriction improves the patient's general condition.

If, on the other hand, the intestine becomes gangrenous it should be incised. If the patient's condition remains unimproved, nothing further than incision of the gangrenous loop should be undertaken at this time. If this will not give relief there is very little to be hoped for in subjecting the patient to radical operation or intestinal resection.

If the hernial contents shows positive evidences of gangrene without the existence of an inflammatory process outside of the intestinal walls, primary resection can be resorted to if the patient is sufficiently strong to warrant the operation. If there seems to be some doubt regarding the advisibility of subjecting the patient to the shock following an intestinal resection, incision of the gut only should be done. Of course, there is some difference of opinion regarding the mortality rates that follow this procedure. I am convinced, however, that resection should not be done unless the patient's general condition is fairly good.

If local or inflammatory evidences are found outside of the hernial contents nothing but incision should be effected at the primary operation. No attempt should be made to break up the adhesions that bind the hernia to the hernial canal. Division of the constriction with incision of the intestine will give temporary relief in these cases, and offers little risk of spreading the inflammatory process. If these cases have advanced to a stage in which general peritonitis has developed, little relief can be expected from any operative procedure.

The operation advised by Helferisch-intra-abdominal intestinal anastomosis between the two limbs of the strangulated gut-has no place in the primary treatment of strangu

lated hernia. If a fistula has resulted, or an artificial anus remains, Helferisch's method may be employed advantageously.

There is one statement that is mentioned often in considering the operative procedures advised for strangulated hernia that seems to me without foundation. I refer to anchoring of the intestine in making an artificial anus, or in simple incision of the gut. If the condition has advanced to such a degree that it is not advisable to reduce the strangulated intestine, it will usually be found that there is inflammatory reaction sufficient to result in the formation of adhesions that are firm enough to hold the intestine in place. No manipulation is justified, and no suturing advisable, in the attempt to hold the intestine from falling back into the peritoneal cavity.

Discussion.

SURGERY TWO HUNDRED YEARS AGO.

To look backward a couple of hundred years and catch a glimpse of the condition of the profession of those days affords much interest to the student of historical items, and at least passing thought to the man who is wont to look but little upon that which is of another era.

Contrast necessarily brings out criticism inasmuch as contemporary thought is quite likely to be egotistical, and the past therefore is bound to suffer upon comparison with the present.

But aside from this human frailty, there is no doubt just occasion for a sense of satisfaction in the real development that has taken place in the field of surgery during the last two hundred years.

From a very well-preserved copy of a pretentious surgical treatise of the time indicated we append some fac simile pages. The portion of the Author's Preface is reproduced to show the custom then obtaining of setting forth in quite extensive detail the advantages the writer of a book has enjoyed, either as a sort of apology, extenuation or advertise

ment.

The illustrations are sufficiently explained by the text adjoining each.

[EDITOR.]

THE

AUTHOR'S PREFACE.

A

FTER having ftudied Phyfic with great Affiduity above four Years in our German Universities, my Affections, being ftrongeft for Anatomy and Surgery, led me to the then celebrated Profeffors RUYSCH and RAW, at Amfterdam, in the Year 1706; whofe anatomical and chirurgical Demonftrations I diligently attended for about the Space of a Year. During which Time I was alfo employed in frequent Diffections, and in trying chirurgical Operations upon dead Subjects; in the mean time omitting no Opportunities of being prefent at the Performance of any confiderable Operation by these Profeffors, or by the other eminent Surgeons of the fame City, as VERDUIN, BORtel, KoenerdinG, &c. By which Means, joined with an attentive Reading of the best Writers, I acquired a confiderable Knowledge in Surgery.

But being defirous of all Helps to render myself ftill more expert and fuccefsful in the Practice of this Art, there being at that Time a fharp War in Flanders, betwixt the French and Dutch, in the Summer following, viz. in the Year 1707, I went from Holland to the Dutch Camp in Brabant, that I might inspect, and obferve the Practice of the English, Dutch, and German Surgeons, who there attended. Thus, through many Dangers and Hardships, I spent this whole Summer in the Hofpitals of the Camp, for the Sake of Improvement. But in Autumn I went from Brabant to Leyden, and spent the whole Winter in attending the Lectures of the then celebrated Profeffors in that Univerfity, BIDLOO, ALBINUS fenior, and BOERHAAVE: And thus I continued till the Beginning of the Summer 1708. After which, having taken my Degree of Doctor, I returned again to the Camp, where I found large Opportunities of learning and improving myself in Surgery, from the Multitude wounded, &c. in the feveral bloody Fights, particularly at the Siege of Lifle, and the Battles of Audinarde and Wynnen

dale.