Dr. JAMES BRADLEY, ON STRANGULATED HERNIA. (Concluded from our last, pp. 112-121. )

THERE are two prominent varieties in the phenomena

of strangulated hernia, which are peculiarly deserving of attention, and which, perhaps, are dependent on the degree of stricture in the parts strangulated, as well as on some peculiarity in the constitution. The first is, where the violence of the stricture is such, combined probably with other causes, as to occasion excessive and continued sickness, which fails not to arrest the action of the heart and arteries. The circulation is of course lessened, and the patient becomes cold, ghastly, and dejected. He sighs, he moans, the tunica conjunctiva and countenance are extremely pallid, the eyes sunk within their sockets, the nostrils contracted, and the living principle is nearly extinct, before the surgeon is often aware of the danger. Here the pulse are at first slow, soft, and sometimes full; but as the disorder advances, they become more contracted and generally quicker; and if the stricture be removed before the powers of nature are too much exhausted, they will be increased for a while, both in force and velocity; but if on reduction, they fail to rise, and only increase in quickness, then considerable danger is to be apprehended.

The

Under every shade of this variety, the operation of opening the sac is attended with considerable risk. Under every aspect of the second variety, there is more force and action in the pulse, more general heat, freer intervals from sickness, and fewer symptoms of asthenia. pulse, under these circumstances, are quicker, and generally more tense, and in the middle stage of the complaint, are from 100 to 120; and if the stricture be overcome, without a division of the sac, they will decrease suddenly, both in number and in force; and the operation of opening the sac, in the usual manner, if not delayed too long, will in general succeed. Here the surgeon can oftener form, though still an incorrect, yet rather a better idea as to the state of the parts concerned in the hernia, than in a case of the first variety, where the greatest mischief sometimes exists, although not clearly indicated by any external criteria. It is in cases of this kind, (meaning the first class of symptoms) that delays are of the greatest moment; and it is also under circumstances like these, that the debilitating plan should be guarded against. Bleeding is mostly injurious, and purgatives can have no other effect than increasing the sickness; and the use of cold applica(No. 139.)

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tions are less indicated, on account of their sedative effects, and the general coldness they cannot fail to increase. The propriety of the tobacco-clyster is doubtful, from its sedative powers; especially, where the pulse are very slow and languid, and the sickness extreme; for this state is very similar to that produced by the action of tobacco. itself. In most of the cases, where I have seen the tobacco-clyster administered, and where it failed, (which it generally does) it did harm, either by increasing inflammation or debility.

If the above classification of the symptoms peculiar to strangulated hernia be founded on the broad basis of observation, it is obvious, that the difference of opinion as to some of the means usually employed in its reduction. is easily reconcileable. The propriety of bleeding has long divided the opinion of practitioners, and is a subject of dispute not yet fully settled, and which is, perhaps, owing more to the want of a proper arrangement, or discrimination of the phenomena attendant on this affection, than to any other cause.

Although bleeding in the first class of symptoms be generally inadmissible, yet sometimes cases occur, where it may not be improper. For instance, when the pulse is full, though the vomiting and sickness be considerable, drawing off a moderate quantity of blood, will seldom do harm, either by increasing sickness, or debility; but under most other circumstances of this variety of the complaint, I believe it will be inadviseable.

In the second class of symptoms, blood-letting may oftener be had recourse to, but even here, it ought to be employed with considerable caution; for where the parts have suffered severely from strangulation, or are in a state of inflammation, bordering on gangrene, and where the powers of life are weakened, which is known by a low, feeble, and sometimes a quick contracted pulse, together with other symptoms of debility, this remedy had better be omitted.'

On the subject of blood-letting, three distinct objects present themselves to the mind of the surgeon. The first is, the probability of removing the stricture, or relaxing the tendon. The second is, to abate local inflammation within the hernial sac; and the third is, the influence which this remedy may have over the health of the patient, subsequent to the operation for bubonocele.

Although bleeding in the first intention be seldom successful, yet, if productive of no immediate or remote in

jury,

jury, it may always be adviseable to employ it; but if on the other hand, we be certain, that under some circumstances it is capable of doing harm, it will always be necessary to exercise some caution and judgment, before its adoption.

As to the second intention, or the influence which bleeding may have in abating local inflammation, we must ob serve, that as long as the stricture continues, the mischief will proportionally, and progressively increase; therefore, this operation can have little or no effect, as long as the cause continues to prevail.

As to the operation for the strangulated hernia being rendered more precarious, in consequence of previous phlebotomy, it is a subject of vast importance, and on which hinges, in a great measure, the propriety of bleeding at all; but on this subject, surgeons of the present day are not perfectly agreed. Mr. Wilmer says, that bleeding renders the operation more dangerous. This theory, though not universally, yet I believe is in general true, when the practice is carried to the extent which is usually recommended.

It is much to be wished, that some surgeon who hath great opportunities for observation, would devote his attention particularly to this subject, and point out the circumstances, under which phlebotomy is, or is not, improper in this affection; as this would always be a very important directory, especially for young surgeons, who are guided more by authority than their own judgment. Mr. Hey is quite undecided on this subject, and in his comment on Mr. Wilmer's assertion, that bleeding increases the danger of the operation, he advances as a reason to the contrary, the circumstance of the patient dying under symptoms of ileus, or an inflammatory affection of the intestines; and that these could not have been caused from bleeding. That symptoms of inflammation do appear, on dissection, in the intestines after death, as Mr. Hey hath represented, is not denied; and that these appearances are occasioned by previous phlebotomy is an absurdity will be universally admitted, but that they point out on the other hand, the necessity of blood-letting, previous to the operation of bubonocele, is extremely questionable, except it can be demonstrated, that these symptoms are purely the effect of stricture; and even here, there would be many exceptions arising out of the circumstances of the case; but we know, as has before been stated, that either a new set, or an aggravation of the old symptoms, succeed the division of the sac, and we also have reasons to apprehend, that the use of the tobacco-clyster hath some share

in giving rise to symptoms, which, especially after the ope ration of opening the sac, will be more fully displayed; and besides, it is well known, that death will bring about considerable changes in the aspect of morbid appearances. Parts that were slightly inflamed in the living, will exhibit all the signs of high inflammation, or even extravasa'tion, in the dead subject. Another circumstance worthy of remark, is, that ileus or inflammation of the intestines is generally superinduced on the opening of the sac, and it rarely happens, on the other hand, that this affection alone proves fatal, after the stricture is removed, without a division of the sac. It therefore follows, that these inAammatory appearances afford no infallible data for determining on phlebotomy, previous to the operation of bubonocele. For these, and other reasons, already advanced, Mr. Hey's objection does not, in my opinion, satisfactorily or conclusively bear on Mr. Wilmer's position, which is certainly much too unqualified.

Purgatives, I still think, may be adviseable under some circumstances of this complaint, particularly in the second class of symptoms above specified; and especially when the vomiting is not frequent, and the intervals tolerably free from sickness. Such as are recommended in my last communication, may not be improper; if, however, they should either increase the sickness or vomiting, they ought no longer to be persisted in.

As to opium, in the cases where I have employed it, I could not discover that it any way contributed towards removing the stricture; yet notwithstanding, I think this renedy may frequently be employed with great advantage, as it not only allays irritation, but induces sleep, which the patient is generally deprived of, whilst the stricture continues. It also stops the vomiting, and arrests, or retards, the progress of diseased action; but, however, as soon as the effects of the opium disappear, all the distressing symptoms return with redoubled force. In a case of the first variety, where the symptoms are very severe, and the surgeon from some cause is constrained to defer the operation, opium may be given with the happiest effects; for exclusive of its anodyne properties, it elevates the pulse, cheers the spirits, and diffuses an additional heat over the surface of the body. If, however, the ope ration of returning the sac unopened be intended, this me dicine had better, in general, be omitted; for if performed whilst the patient is under its immediate agency, it will be more difficult to ascertain the removal of the stricture, as is exemplified in Case V.

As to the result of the operation of the taxis, by pressure, as formerly practiced, and continued uniformly to the present time, being a course of nearly twenty years, I' can say, I have succeeded in half the cases I have met with; but whether this practice, on being compared with that of others, be such as to recommend it to general notice, I cannot say. One advantage it seems to possess, namely, that it is productive of no active injury to the parts implicated in the hernia. One disadvantage, however, it may be exposed to, which is, delay, or loss of time, necessarily incurred by the operation; but this inconvenience may be nearly obviated, by the surgeon prescribing to himself a fixed time, of moderate duration, suchas before specified. Another result of this practice is, I have been more successful, cæteris paribus, in early life, than in advanced age, in women than in men, and in hernias recently strangulated, oftener than those of longer duration.

The danger formerly attending the operation for the strangulated hernia, rather than the difficulty of performing it, suggested a variety of means for its reduction. A whole routine of these was employed, and often repeated, before the surgeon thought himself warranted in exposing his patient to so great a peril. Hence, that procrastination, which involved in itself such fatal consequences.

Instead of trifling away time, by employing and repeating the means usually recommended, and which afford a very small and uncertain prospect of success, and doubtfully compensating the injury arising from delay, we ought to adopt the few prompt remedies which experience has confirmed to be the most efficacious; and if these fail, the operation should be no longer delayed. For this principle we ought never to lose sight of, namely, in proportion as the disease advances, less chance there will be of the operation succeeding; and the plan generally adopted, previous to the operation, when pursued to its usual extent, is of such a debilitating nature, as cannot fail rendering the operation still more precarious.

The reason why my practice, in the preceding, as well as in the other cases in the sequel, were not in unison with this theory, was, from the particular desire I had of giving full trial to pressure; and from the conviction, at the same time, I had of my patient's sustaining very little injury; but I must confess, in future, I shall be less tempted to expose a patient to any risk from procrastination, as I am persuaded, that our principal dependence on pressure is within the first hour of its application,

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