the heart, are almost immediately fatal. Mere punctures, however,
of these parts, have closed for a time, and in some cases even
permanently. All wounds of the chest, though not involving bloodvessels
of a large size, are productive of severe consequences—effusion of
blood or bloody fluids into the cavities, escape of air into the
external cellular tissue, collapse of the lung, and inflammation and
its results, are always to be dreaded. The danger is not uniformly
tantamount to the extent of injury inflicted. Individuals have
recovered from extensive wounds causing profuse hemorrhage, and great
displacement and laceration of the parts; whilst, from much slighter
injuries, untoward and fatal consequences have quickly resulted.
Wounds may penetrate the chest, and be continued into the abdomen;
the stomach, liver, and intestines—one or all—may be perforated as
well as the lung; in such cases the hemorrhage is in general speedily
fatal. Injury of the intercostal arteries, and of the mammary and its
branches, is attended with serious bleeding. It is easily arrested,
however, by pressure. A piece of fine linen is pushed into the wound,
followed by charpie, so as to form a small bag within the chest, a
little larger than the opening; by pulling this gently outwards and
fixing it, efficient pressure is made on the bleeding vessel. At the
same time the motions of the chest are to be restrained by bandaging;
indeed this is necessary in almost all injuries of that part. When
reaction has been established, antiphlogistic treatment must be
pursued, and it generally requires to be extremely active. Bloody,
serous, or purulent fluids, lodging in the cavity of the pleura, are
to be evacuated, if need be, either by incision or by enlargement of
the original wound. In the course of the cure hectic usually supervenes
to a greater or less degree, and requires the reverse of the previous
treatment.
AFFECTIONS OF THE ABDOMEN.
Inflammation of the peritoneum, when idiopathic, is generally treated
by the physician. But it occurs in consequence of wound, obstruction
from hernia, or affection of the lower bowels. There is a burning heat
in the belly; the pain is constant and increasing, much aggravated
by the slightest pressure or exertion of the abdominal muscles, and
the patient, in consequence, lies with these muscles in a state of
relaxation. The pain is of a very different character from that
arising from spasm, induced by the irritating nature of the intestinal
contents, which supervenes in paroxysms, and is relieved by pressure
or by evacuation. In inflammation the countenance is very anxious, and
generally pale; the extremities are cold and bathed in perspiration;
the patient vomits frequently; and the bowels are generally
constipated. The pulse is small, wiry, and rapid.
_Hernia_ has been classed with tumours. It is a swelling, but of a
peculiar kind, and attended in some states by peculiar symptoms. The
term rupture is in common use instead of hernia, but was at first
applied from a false notion of the disease. There is a descent of
viscera, but not often rupture of the parietes. By hernia is meant
protrusion or escape of the contents of any cavity, but the term is
most frequently applied in regard to the abdomen. The protrusion
may occur at various parts of the abdomen; through the diaphragm,
constituting _Phrenic_ Hernia; through the umbilicus, constituting
_Exomphalos_; through the dilated apertures for transmission of
vessels, constituting _Ventral_ Hernia; through the inguinal canal,
constituting _Inguinal_ Hernia; through the crural aperture,
constituting _Crural_ or _Femoral_ Hernia. The most frequent forms
are the inguinal and crural,—the effects of pressure or action of the
muscles on the abdominal contents being concentrated towards the lower
part of the cavity. It is but rarely that the bowels protrude through
the sacro-ischiatic notch, or through the obturator foramen, or by the
side of the vagina, or betwixt the bladder and rectum.
It is of great importance for the student to study attentively and
reflect on both the healthy and morbid anatomy of this disease. When
a hernia is strangulated, there is an absolute necessity for early
interference; the bowels are obstructed, and their action inverted;
feculent vomiting ensues, and enteritis is threatened, with all its
dangerous consequences. He may meet with the affection at a very
early period of his practice, and may be so situated as to command
no assistance or advice; he must be guided by his own judgment and
knowledge. He should be well aware of the relations of the parts
to each other, and the changes likely to have been occasioned by
the disease. If, through delay, the patient lose his life, or if an
operation be attempted, and its object improperly accomplished, or
not accomplished at all, his reputation may be blasted. But if he
interferes skilfully, and at the proper time, and save his patient,
relieving him at once from all his painful and dreadful symptoms,
great credit and professional fame may be in consequence acquired. An
examination of the healthy anatomy is not sufficient; many changes
take place, which mere anatomical and physiological knowledge could
never anticipate. Extraordinary displacements and adhesions occur. The
parts are altogether changed; and repeated examination of the morbid
state alone can impart the requisite knowledge to one previously well
acquainted with the healthy structure.
In consequence of laceration or separation of fibres, hernia may
occur suddenly, and even in the best formed parts, from very violent
exertion—as in leaping, wrestling, pulling, lifting heavy weights;
from sudden exertion of the abdominal muscles in any way; from blows,
&c. Or the protrusion may come on gradually, after slight exertions,
where the tendons are naturally weak or deficient; or it may be
slowly induced by repeated and almost constant muscular action, as in
urinary, intestinal, and pulmonary complaints: in such cases, slight
pain is usually felt at the site of the protrusion before the tumour
is perceived. The disease is often congenital. But the common cause
of abdominal hernia is powerful action of the abdominal muscles,
compressing the viscera to a greater or less degree, and with more or
less suddenness; the viscera resisting the compressing force, react on
the parietes, and these, yielding at the points which are naturally
weak or deficient, permit enlargement of the coerced cavity by
protrusion of part of the contents. When the compression and reaction
are sudden and violent, the protrusion is the same; but when the former
are not sufficient to overcome the cohesion of the parietes by a single
occurrence, by repetition the morbid end is gradually effected, the
hernia is proportionally slow in making its appearance, and gradual in
its increase.
To understand the nature of _congenital scrotal hernia_, the student
must recollect that the testicle in the fœtus is lodged in the cavity
of the abdomen immediately below the kidneys, and resting on the psoas
muscle; that it gradually descends into a process of peritoneum,
called spermatic, which extends from the general peritoneal cavity
down towards the scrotum, and which ultimately constitutes the tunica
vaginalis. The orifice of this peritoneal pouch not closing immediately
after the descent, may permit a fold of intestine to slip into its
cavity, and remain in contact with the testicle. Or the testicle may,
though rarely, contract in the abdomen an adhesion to a portion of
bowel, and in its descent bring this along with it. In either case the
bowel remain in its new situation, and constitutes congenital hernia.
_Hernia infantilis_ differs from the hernia congenita, and is a kind of
protrusion peculiar to the early period of infancy. In the congenital
form the protruded intestine is in immediate contact with the testicle,
and surrounded by the tunica vaginalis testis; but in hernia infantilis
a process of peritoneum is interposed betwixt the intestine and the
vaginal coat. The affection occurs after the abdominal aperture of the
spermatic process has closed, but before the rest of that process has
become incorporated with the spermatic vessels and their surrounding
cellular tissue. In fact, only the peritoneum proper has closed, and
forms the septum between the cavities of the abdomen and of the tunica
vaginalis; but being insufficient to withstand the impulse of the
abdominal contents, yields before it, and descending along with the
protruding portion of bowel, forms its envelope, or the proper hernial
sac, within the cavity of the tunica vaginalis.
Such is the opinion generally adopted in regard to the nature of hernia
infantilis; but its accuracy is doubtful. It seems more probable that
the bowel, covered by a fold of peritoneum, is protruded into the
cellular tissue of the spermatic chord, after closure and contraction
of the spermatic process, and descending till it reach the upper and
posterior part of the tunica vaginalis, adheres to this tunic, bulges
it forwards, and is covered by it. On cutting down in such a case, the
hernial tumour may appear to be lodged within the tunica vaginalis;
whereas the bowel is actually placed exterior to the tunic and behind
it. Indeed, the case is similar to the common scrotal hernia, only the
tumour is behind, not anterior to the vaginal coat. And this relation
of parts is more apt to occur in the infant than in the adult; for in
the former the testicle does not for some time descend fully into the
scrotum, and whilst it is lodged in the groin a fold of peritoneum
protruded into the spermatic chord may soon contract adhesion with
the tunica vaginalis, afterwards descending along with it and the
testicle. The subjoined case, illustrative of the preceding statement,
came under my observation in 1814.—J. S., æt. 21, was admitted into
the Royal Infirmary, with symptoms of strangulation which had been of
eight days’ duration. The hernia had existed from infancy; it was on
the right side, and tolerably large. In the operation, on dividing the
integuments and various coverings, a sac was opened, which proved to be
the tunica vaginalis, containing the testicle, a considerable quantity
of serum, and a large, smooth, transparent tumour above the testicle
and behind the posterior layer of the tunica vaginalis. The operator
was puzzled, but finally determined on cutting into this tumour;
it proved to be the hernial sac, covered by the tunica vaginalis,
containing three or four ounces of serum and a portion of omentum. The
protrusion could not be returned; after relieving the stricture, the
omentum was cut away, and the bleeding vessels tied separately. The
patient died on the third day after. An analogous case is on record;
and a third has been related to me by an old and experienced surgeon:
in that instance, both the anterior and posterior layer of the tunica
vaginalis, together with the true sac, were simultaneously divided;
omentum and intestine protruded into the vaginal coat, and for a time
the opening through the posterior part of that cavity and sac was
mistaken for the inguinal ring. On extension of the incision, the
nature of the case became more apparent, the stricture was relieved,
and the protrusion reduced. A case, in many respects similar to those
above described, occurred a few years ago in my practice at the North
London Hospital. It is recorded in the _Lancet_ and in the _Practical
Surgery_.
Children are sometimes born with deficiency of the umbilicus, and
protrusion of bowel into the loose cellular tissue of the umbilical
chord; the disease is termed _congenital exomphalos_.
Almost all the viscera of the abdomen and pelvis are liable to
protrusion—the stomach—the spleen—the omentum—the great and small
intestines, and even some of their most fixed parts—the ovaria—the
bladder. Also, right portions of the viscera occasionally escape on the
left side of the parietes, and the left at the right.
Hernial protrusion has received different names, according to the
nature of its contents. When composed of a portion of intestine, it
is termed _Enterocele_; _Epiplocele_, when composed of omentum; and
_Entero-epiplocele_, when both intestine and omentum have escaped; and,
as already observed, different names are also applied, according to the
situation of the protrusion.
The inguinal and crural forms of hernia being the most common, will
chiefly occupy our attention. The inguinal is divided into _true_ or
_oblique inguinal_, and into _direct_ or _ventro-inguinal_. In the
oblique, the protrusion passes along the inguinal canal. This course
is in young persons short; but as the muscles become developed it is
lengthened to about two inches, reckoning from the external ring to
the funnel-like opening through the transverse fascia. The appearance
of the swelling in this canal leads to diagnosis betwixt the oblique
and direct hernia; but in chronic cases, this distinction is often
in a great measure done away with. In large and old oblique ruptures
the neck of the tumour is shortened, and the openings of the canal
are approximated and more in a direct line. They are also immensely
dilated, being often enlarged to such an extent as to admit all the
fingers of the hand, when placed in a conical form,—and this even in
the living body, the loose integument receding along with the tumour.
The epigastric artery is situated behind the neck of the sac, on its
inner side; and it is much displaced inwards in cases of old standing.
The direct hernia passes through the parietes opposite to the external
ring, and does not come in contact with the spermatic chord until it
has reached that point. Its neck is short, and the epigastric artery
is on its outer side. The coverings of the two tumours are different.
Those of the oblique are such as the chord possesses—a prolongation of
the transverse fascia, a covering from the cremaster muscle, fibres
from the edge of the external ring, and the superficial fascia of the
abdomen. The direct has only the last. A very old woman was operated
upon in the North London Hospital a few days ago, for strangulated
hernia of several days standing. The tumour was high in the inguinal
region: on cutting down upon it, the tendon of the external oblique
was found to cover it completely. The external ring was occupied
by a mass of fatty matter, which probably had been displaced. The
tendon was divided, and the sac, of considerable size, exposed. The
opening through which the protrusion had taken place was very small,
and situated a good deal to the mesial line of the internal aperture
of the canal. The hernia was at the time of operation supposed to be
ventro-inguinal. The patient was relieved for a time, but eventually
sunk exhausted. An opportunity was thus unfortunately afforded of
verifying the opinion formed. The hernia had two proper coverings, the
superficial abdominal fascia and the tendon of the external oblique.
The opening was inside the epigastric. The portion of bowel which had
been extruded and returned was very tender, but it had adhered to the
peritoneum, close to the place where it had been confined.
The oblique inguinal, when recent and small, is termed Bubonocele; but
when large, it generally descends into the scrotum—oscheocele—of course
exterior to the tunica vaginalis; and in females into the labium. The
tumour often attains an immense size, from continued application of the
causes that produced it,—laborious occupations, or straining of muscles
in any way. When of long duration, and not attended to, it is not
uncommon for the swelling to hang as low as the middle of the thigh, or
even down to the knee. In such cases, the testicles often are wasted,
and the penis concealed; indeed the skin of the penis, as well as of
the lower part of the abdomen, is stretched over the tumour. Crural or
femoral hernia is, on the contrary, seldom larger than a small apple.
Sometimes, but very rarely, the tumour is of large dimensions. I have
seen one containing the transverse arch of the colon, the omentum, and
a yard and a half of small intestine. The tumour is represented some
pages further on.
When a very large hernia remains always full, the cavity of the abdomen
diminishes in size; in fact, it adapts itself to its contents; and this
must be kept in mind when interfering with such cases.
Inguinal hernia most frequently occurs in males, the femoral in
females; and the reason of this is obvious on comparing the size
of the inguinal and crural openings in the sexes. In the male, the
inguinal opening is much larger than the femoral; in the female, the
femoral is the larger,—the inguinal is small, containing only the
round ligament of the uterus. The causes of hernia act equally on both
openings, and therefore it is to be expected that protrusion will take
place where there is the least resistance, where the parietes are most
deficient.
Hernia can seldom be mistaken for any other swelling, by one at
all acquainted with his profession, and who makes his examination
attentively. The history, and the mode of its appearance, are to be
attended to. The swelling proceeds from above—at times it recedes on
the patient lying on his back and making pressure on the swelling—a
distinct impulse is communicated to it on exertion of the abdominal
muscles, as in coughing—the tumour is generally elastic, and its neck
can be felt extending from the lower abdominal aperture. Also, the two
kinds, inguinal and crural, can scarcely be confounded with each other;
the former is above, the latter below, the ligament of Poupart. It will
be proper, however, to enumerate shortly the diseases for which hernia
may be mistaken.
_Cirsocele_ may be confounded with inguinal hernia. Cirsocele, being a
varix of the spermatic veins, enlarges on coughing and during the erect
posture, like hernia; but in general the composition of the tumour
can be ascertained by the feel which it imparts when handled,—the
veins feel like a handful of earth-worms. Besides, the swelling is
made to disappear, on emptying the dilated veins by pressure upwards;
and, if the surgeon then firmly compress the inguinal aperture, the
tumour will rapidly reappear, on account of the venous flow being
interrupted, particularly if the patient exert his abdominal muscles,
or assume the erect posture. Whereas, had hernia existed, the swelling
could not have been reproduced; and, on the patient being directed
to cough, a distinct impulse would have been felt with the finger.
_Hydrocele_ of the tunica vaginalis may be confounded with scrotal
hernia, if its distinctive characters be not understood or attended
to. The pyramidal swelling presents an equal surface, fluctuates, and
is generally diaphanous; its formation is gradual, commencing at the
lower part, and slowly ascending; the testicle cannot be readily felt
at the bottom of the scrotum; there is no swelling at the inguinal
canal, and the chord is felt free; the tumour is not affected by the
position, motion, or exertions of the patient. These circumstances
plainly indicate the nature of the case. Bubo, sarcocele, and acute
swelling of the testicle, are sufficiently distinguished from hernia
by their situation, form, feel, and history, and cannot be confounded
with it save by the profoundly ignorant. _Hydrocele of the spermatic
chord_ is more likely to lead to deception when large; but it is
generally small and circumscribed, involving the middle of the chord,
leaving the inguinal aperture free, and the upper part of the spermatic
chord distinct. Besides, whatever may be its size, its formation is
always slow and indolent,—it is never capable of being pushed into the
abdomen, and it is unaffected by those circumstances which contribute
to mark hernia. But hydrocele of the chord and hernia may coexist, as
in the following instance:—A gentleman had swelling in the course of
the spermatic chord for many years, while in a warm climate. Bandages
were applied, and great pain thereby occasioned. After his return to
this country, pain in the belly and vomiting seized him on a Monday
morning, and continued with more or less violence till the Sunday
following. Then the vomiting became feculent, the belly excruciatingly
painful and tender, the tumour tense, and the pulse weak. A physician
opposed operative measures, having been convinced that his former
complaint was a hydrocele of the chord. But I conceived that the
symptoms warranted cutting down on the parts, and did so. A hernia was
found containing omentum and a fold of bowel; a hydrocele of the chord
lay alongside of it.
Crural hernia has been mistaken for bubo, and _vice versâ_. Lumbar
abscess and varix of the femoral vein are also supposed to resemble it
in some measure. The situation and form of the tumour in lumbar abscess
is very different from those of hernia; and the mode of examination
recommended in regard to cirsocele is equally applicable to the
detection of dilated femoral vein. The distinctions between crural
hernia and bubo are too obvious to require mention.
Patients with unreduced hernia are constantly in great danger; as
bruising of the swelling, or accumulation of feces in the protruded
bowel, are likely to occasion very unpleasant consequences. They are
generally troubled with indigestion, flatulence, and constipation; a
slight degree of constriction at the neck of the tumour produces an
obstruction to the intestinal contents; the viscera in the sac have not
due support and pressure, hence accumulations take place in them, and
may be productive of serious and even fatal effects. No protrusion,
in which these circumstances are likely to occur, should be allowed
to exist, if possible. So afraid were the ancients of allowing hernia
to remain unreduced, that it was their custom to cut all patients
labouring under rupture who would submit to the operation; and this was
generally performed by itinerant quacks. They returned the protrusion
without opening the sac, and then the neck of the tumour was either
stitched up, or tied along with or without the spermatic chord. The
actual cautery, and the most powerful caustics, were also applied
to the parts by some, and dreadful were the effects; yet after the
neck of the sac had been destroyed, and perhaps the bone exposed and
exfoliated, protrusion again took place by the side of the cicatrix.
By many, castration was considered necessary for the cure of scrotal
hernia. Such harsh measures were founded on erroneous and imperfect
ideas of the nature of the disease, which are not often to be met
with in the present day. Operations for unincarcerated hernia are not
justifiable, and those who have operated in such circumstances give a
very unfavourable account of the experiment.
The external applications employed to reduce hernia are various.
Some are supposed to produce corrugation of the integuments, and
contraction of the cremaster muscle, and thereby to force up the
protruded intestine; others are of an astringent character, and their
administrator may gravely believe and say, that by them he expects
to tan the living scrotum, to reduce the hernia, and to present an
insuperable obstacle to its reproduction. But all such means are
visionary, and practically ineffectual; no external or internal remedy
can attenuate and reduce the hernial sac, remove adhesion, or produce
contraction of the tendinous and rigid apertures.