صور الصفحة
PDF
النشر الإلكتروني

fined to its history, its anatomical structure, and to a comparison with other diseases which resemble it. Among many meriting particular attention, the following observations are selected:

"Carcinoma sometimes condenses the surrounding substance so as to acquire a capsale; and then it appears, like other sarcomatous tumours, to be a part of new formation: in other cases the mammary gland seems to be the nidus for this diseased action. The boundaries of the disease cannot be accurately ascertained in the latter case, as the carcinomatous structure, having no distinguishable investiment, is confused with the rest of the gland. In either instance carci noma begins in a small spot, and extends from thence in all directions, like rays from a centre. This observation will serve to distinguish it from many other diseases which, at their first attack, involve a considerable portion, if not the whole of the part, where they occur. The progress of carcinoma is more or less quick in different instances. When slow, it is in general unremitting; at least I am inclined to think that the disease, though it may be checked, cannot be inade to recede by that medical treatment which lessens the bulk of other sarcomatous tu mours. I state this opinion however with some hesitation, for I have been informed by surgeons, that diseases, the event of which proved them to be carcinomatous, have suffered a considerable reduction in size by that kind of local treatment mentioned in the preliminary observations. This circumstance affords, in my opinion, another criterion, by which it may in general be distinguished.

This obdurate and destructive disease excites the contiguous parts, whatever their nature

may be, to the same diseased action.

The

skin, the cellular substance of muscles, and the periosteum of bones all become affected, if they are in the vicinity of cancer. This very striking circumstance in the history of carcinoma distinguishes it from most of the diseases already described. In medullary sarcoma the disease is propagated along the absorbing system, but parts immediately in contact with the cnlated glands do not assume the same diseased actions. Neither in the tuberculated species does the ulceration spread along the skin, but destroys that part only where it covers the diseased glands.

"It was observed by Mr. Hunter that a disposition to cancer exists in the surrounding parts, prior to the actual occurrence of the diseased action. This remark, which is verified by daily experience, led to the following rule in practice: That a surgeon ought not to be contented with removing merely the indurated or actually diseased part, but that he should also take away some portion of the surrounding substance, in which a diseased disposition may probably have been excited. In consequence of this communication of disease to the contiguous parts, the skin soon

becomes indurated, and attached to a carcinomatous tumour, which, in like manner, is fixed to the muscles, or other part over which it was formed.

"As a carcinomatous tumour increases, it generally, though not constantly, becomes unequal upon its surface, so that this inequa lity has been considered as characteristic of the disease, and it is a circumstance which deserves much attention. A lancinating pain in the part frequently accompanies its growth; but in some cases this pain is wanting. It attends also on other tumours, the structure of which is unlike carcinoma; of which I have given an instance in speaking of pancreatic sarcoma. This pain cannot therefore be considered as an infallible criterion of the nature of the disease.

"The diseased skin covering a carcinomatous tumour generally ulcerates, before the tu mour has attained any great magnitude, a large chasin is then produced in its substance by a partly sloughing, and partly ulcerating process. Sometimes, when cells contained in the tumour are by this means laid open, their contents (which are a pulpy matter of different degrees of consistence, and various colours) fall out, and an excoriating ichor distils from their sides. This discharge takes place with a celerity, which would almost induce a person ignorant of the facility with which secretion is performed, to believe that it cannot be produced by that process."

This classification, the author seems aware, is not complete; such as it is, it has assisted him in his inquiries, and he offers it for the assistance of others. Some well executed plates, and the history of the particular habits or tempera

ments in which the different kinds of tumours most frequently occur, wonid have added much to the value and utility of these observations, excellent as they are in many respects.

The next subject that occupies a considerable part of this volume, is an account of diseases resembling syphilis. Here again we find our author enrolling himself under the banners of Mr. Hunter. The existence of some disease resembling lues venerea, did not escape the acute penetration of that great man, and Mr. Abernethy has considerable merit in prosecuting so curious and important a part of surgical pathology. In this interesting inquiry, the author proceeds upon a question that is assumed--he takes it for granted, that the venereal disease is regular and progressive in producing constitutional symptoms, and that these never disappear unless mercury be employed; whereas those diseases resembling syphilis in many respects, are irre

gular in their progress, and disappear spontaneously, or get well without the aid of medicine. If these premises be conceded, (and all our histories of the venereal disease seem to be in favour of them,) the conclusions seem legitimately deduced, and the author seems warranted to affirm, that symptoms which have the appearance of venereal, do arise in consequence of the contagion of some other morbid poison, and that these symptoms differ from syphilis in several important particulars. As the frequent occurrence of these disorders seems to prove that they are increasing of late, other practitioners must meet with them, and thus the arguments here brought forward will be subjected to the strict test of multiplied experience, by which they must ultimately stand or fall. The cases related by Mr. Abernethy are very striking, and suggest many curious reflections, respecting the modifications of syphilis, or the various changes which morbid poisons undergo in different constitutions and in different circumstances. The primary sores which are capable of producing secondary symptoms like those of syphilis, do not possess any uniform character; there seems to be no characteristic mark by which these pseudo-syphilitic diseases may be distinguished. The history and the progress of the complaint must direct in forming a diagnosis. The effect of mercury on these diseases is various.

"It sometimes cures them very suddenly and very differently from the gradual amend ment which it produces in truly venereal diseases. Sometimes, however, these diseases yield more slowly to its operation, and are cured permanently. Sometimes the diseases recur in the same parts after a severe course of mercury; sometimes mercury merely checks the disease, and can scarcely be said to cure it; in which case it seems important to support the strength of the constitution, and to keep up that mercurial effect which controuls the disease, and can be borne without material derangement of the constitution for a great length of time. Sometimes also the use of mercury aggravates these diseases." With regard to the practice to be followed in these puzzling and perplexing cases, Mr. Abernethy lays it down as a general rule of conduct, that surgeons are not to confide in their own powers of discrimination, but in all cases of ulcers arising from impure intercourse to give mercury sufficient to affect the constitution slightly, and to endeavour to remove quickly the local disease.

The remaining contents of this work are miscellaneous. They consist of some important observations on injuries of the head-on aneurism--on the operation of puncturing the urinary bladder--on tie douleureux---and lastly, on the removal of loose substances from the knee-joint. Various practical inferences may be drawn from several valuable cases here related. Various too are the reflections suggested to the mind by the perusal of them. A few only can with propriety be stated in this place, and those will be confined to the latter of the two cases detailed, in which the operation for aneurism was performed, and both the patients died. The death of the lady who submitted to the operation for femoral aneurism, is attributed to some peculiar irritability in her constitution, by which she was unusually affected by the operation, and to the disturbance of the parts surrounding the vessel, which necessarily took place during the performance of it. A farther explanation, which appears more plausible, is to say, this patient died from secondary hæmorrhage, and perhaps this hæmorrhage might in some measure be attributed to the manner the operation was performed in, as well as to some peculiarity in the state of the vessel itself. The aneurism was situated in the thigh, about three inches distant from the part where the arteria profunda femoris is given off. Might not the situation where the ligature was necessarily passed round the artery, prevent the coagulation of the blood in the. divided extremity, and thus interrupt that series of actions which produce the complete union or obliteration of it? It sometimes happens, that ulceration takes place in an artery before the coats of the divided vessel are completely united. This fhfortunate occurrence seems most likely to happen, when an artery is taken up near the branching off of a large vessel. A case of this kind is mentioned by Mr. Hunter, where the artery was included in a ligature within half an inch of the profunda femoris; no union took place, no complete coagulum was formed, hæmorrhage followed, and the patient died in consequence of it. Other cases of a similar nature might be mentioned. Perhaps it would be worth inquiring into the practical appli cation of these unfortunate occurrences, and to consider the comparative advantages of tying the artery above or below the branching off of a large vessel, in

those instances where the aneurism is situated very near such a ramification. The operation of puncturing the bladder from the rectum in cases of suppressed urine, has been sanctioned by the experience of Mr. Home and other eminent surgeons. But cases sometimes occur, in which this mode of operating is attended with great difficulty, if not altogether prevented. The chief of these are owing to enlargement of the pros tate gland and false passages in the course of the urethra. In such instances, Mr. Abernethy has punctured the bladder above the pubis, and he recommends this practice as safe and salutary. No ill consequences followed making an opening into the distended bladder, by directing an incision about two inches in length through the integuments between the musculi pyramidales abdominis, then distinguishing the bladder by the finger, and introducing a common trochar obliquely downwards. The elastic catheter was afterwards employed with the

best effects. Both these methods of operating in suppression of urine, it may be remarked, were practised and recommended many years ago by two very celebrated French surgeons, Pouteau and Petit, although the practice has only been lately common in this country.

Monsieur Petit, Traité des Maladies chirurg. tom. iii. speaks of puncturing the bladder above the os pubis, not only as being free from danger, but in terms of great approbation.

The case of tic douleureux is interesting on many accounts: and the practical observations on the best mode of remov ing loose substances from the knee joint deserve attention.

We have thus attempted to give a general view of the important contents. of this volume. To have aimed at a more particular and correct analysis. would have been unnecessary, because the whole work has so many just claims to a careful and attentive perusal.

ART. XXIV. The Anatomy and Surgical Treatment of Inguinal and Congenital Hernia, By ASTLEY COOPER, F. R. S. Member of the Royal Medical and Physical Societies of Edinburgh; Lecturer on Anatomy and Surgery, and Surgeon to Guy's Hospital.

THE treatment of hernia is not one of those rare and curious parts of surgery which it falls to the lot of but few to undertake, or which can be generally referred, like lithotomy, to the surgeon of hospitals or of extensive practice. The complaint itself is one of the very commonest of all the palpable derangements of the human frame, for though the ease with which it is generally borne, and the situation of the parts, prevent its extreme frequency from being universally observed, the youngest and least experienced practitioner cannot fail to have frequent opportunities of seeing it, and the anatomist constantly meets with it in one state or other in casual subjects, It is true that a very small proportion of ruptured persons ever are reduced to the formidable necessity of submitting to surgical operation; but when that operation comes to be required, very prompt decision is often necessary; and, besides, it is no trifling part of the surgeon's office to ascertain the existence of the disease, to distinguish accurately the seat and the species, and to apply those palliative means by which the patient is enabled to go through the common business of life without trouble or risk.

The varieties of hernia are many and

important, and the diagnostic marks are often obscure and perplexed; hence a considerable minuteness is required to render the description of the disease really serviceable to the practitioner; and, as actual subjects or preparations cannot be multiplied, it becomes almost indispensable to give the assistance of engravings on a scale sufficiently large for distinctness and accuracy. Such a description was certainly wanting to the English student, when the author of the work before us undertook the present plan, which we may here mention is only begun; it remains to examine how far the execution corresponds with what will be expected from a lecturer of eminence, and a surgeon to one of the largest and best appointed hospitals of the me tropolis.

In a short preface the author, after explaining his reasons for undertaking the work, professes to draw the whole materials from actual observation, or the communications of friends whose accuracy he can rely on. He says,

"I have almost uniformly, in the following work, avoided quoting the opinions of authors on this part of surgery. This I have done, certainly not from any wish to slight or undervalue the labours of some of the

most excellent physiologists and practitioners that have adorned our profession, but because it did not form a part of my plan to give a history of this branch of surgery, and because I wished to confine myself to the very wide scene of observation afforded by the two noble institutions of St. Thomas's and Guy's hospitals, and to that portion of the practice of this metropolis which I have been personally enabled to authenticate. I have therefore related no case, and given no remark, to the truth of which I cannot vouch; and for the same reason the subjects of all the plates annexed to this volume are from preparations, either in my own possession, or in the anatomical museuni at St. Thomas's hospital, which may at all times be consulted."

The first chapter is taken up with a general description of hernia, and the different varieties of situation and circum stances. Those relating to the sac are of great practical importance, and some singular anomalies are pointed out.

The anatomy of the parts connected with inguinal hernia follows. It is drawn up with the clearness and preci sion of one long accustomed to accurate dissection, and with the illustration af forded by the plates it becomes very in telligible to the reader. Particular pains are taken with the complicated structure

of the crural arch.

guinal hernia, and the marks by which To this succeeds the description of init is distinguished from other swellings of the groin and scrotum. The diagnosis is often practically difficult, nor is it possible for words to impart that skill of tact which is the result of long experiThe distinction between hernia and varicocele is thus pointed out.

ence.

"But of all the diseases of the scrotum, which are ever inistaken for hernia, none is so much so as the varicocele or enlargement of the spermatic veins. Often have I known persons (even the children of medical men) to wear trusses for a supposed hernia, which they complained did not fit, gave them pain, and could not prevent the descent of the tumour, when it was found that the disease was this enlargement of the spermatic veins. "Varicocele has indeed many of the marks of hernia. When large, it dilates upon cough ing, but not otherwise; it appears in the erect position, and retires when the body is

recumbent; and it is first observed near the ring. The only sure method of distinction with which I am acquainted is this: place the patient in the horizontal posture, and empty the swelling by pressure upon the scrotum, then putting the fingers firmly upon the upper part of the abdominal ring, desire the patient to rise: if it is a hernia the

tumour cannot re-appear as long as the prese sure is continued at the ring; but if a varicocele, the swelling returns with increased size owing to the return of blood into the abdomen being prevented by the pressure.

"Some judgment inay also be formed by the feel of the tumour, for that of varicocele is always ropy, as if a bundle of cords were contained within the scrotum."

The causes of hernia are stated to be, generally, those which diminish the resistance of the abdominal muscles, and those which increase the pressure of the viscera. A great variety of specific causes are enumerated, all of which operate, either by producing relaxation of the parietes of the abdomen, or a preternatural stress on its contents. We can

not however agree to the author's asserin hot climates, without a much greater tion that hernia is a more frequent disease body of evidence than is here adduced. In Malta and Egypt it is stated to be very common, and often to be seen of an enormous size. But how little can be is true that travellers and navigators inferred from such vague assertion! It have found most formidable specimens but we are convinced that their opinion of this disease in every part of the globe, of the frequency of hernia has been much biassed by the state of the disease, and habit and opportunity of applying trusses the enormous bulk to which it has been suffered to proceed. In this country the and deriving benefit from surgical as sistance are so universal, that thousands of ruptured persons walk the streets and pursue without inconvenience their usual Occupations, so that a stranger only judging by appearance, might be led to suppose that the disorder was extremely rare. The worst and most unsightly cases are confined by the sense of public decorum to hospitals, workhouses, or private dwellings. Compare this with the supine indolence of the lower classes in Egypt or Turkey, and the brutal neglect with which they are treated, and the reason of the frequency of these miserable objects will soon appear.

On the other hand Mr. Cooper gives indisputable evidence of the extreme fre quency of hernia in this country, espe cially in the hard-working poor when at an advanced period of life. This is so important a fact that we shall quote his words.

"Old age also, 'from the general relaxa tion which it produces, is very frequently accompanied with this disease, so much, that I have been surprised to find but few old

men entirely exempt from it. Since I have had this publication in view I have neglected no opportunity of procuring specimens of this disease, and on inspecting the bodies of old people I have scarcely ever been disappointed in finding either inguinal or femoral hernia. The subjects which I have examined, however, have principally been old persons who have been obliged to labour for their subsistence after their strength became unequal to great exertious.

Those who work hard, and live more on fluid than solid food, are also very subject to hernia; whence its frequency among the poor of this town, who work to the utmost of their strength, and subsist very much upon liquids."

Besides the many obvious causes of hernia here enumerated, there can be little doubt that an original defect of strength in the tendinous parietes of the abdomen largely contributes to the frequency of the disease. Mr. Cooper does indeed mention hereditary conformation; but we much doubt whether this will sufficiently apply to a majority of those numerous cases of hernia that occur in persons of easy circumstances, not exposed to any great or sudden strains of the abdominal muscles, and in whom the disease arises often from so trifling an accident as clearly to prove that the real cause was a natural defect in the resistance of the abdominal ring.

Many very useful directions for the application of trusses are given in the succeeding chapter.

Irreducible hernia and its causes are next described, and some instructive cases are given. The inconvenience from the increasing bulk of the tumour may often be prevented, and even an entire return sometimes procured, by means which are here pointed out.

When the contents of hernia have become so large and encumbered with fat as to render the disease at that time irreducible, it has been recommended previous to any attempt at reduction, to make the patient undergo a course of extraordinary fasting, accompanied with cathartic medicines, and every means used to keep up a free perspiration. It is scarcely to be doubted that such a plan would, after a considerable times be attended with ultimate success; but I have never met with any one who would submit to so severe a regimen, to free himself from a disease, which only gives a present inconvenience, and does not alarm the patient for

the future event.

"A more easy and equally effectual remedy is to apply a bag truss to support the scrotum, and made to lace before. In this way a considerable pressure is steadily preserved upon

the parts, which occasions a gradual absorption of the adipose matter of the protruded hernia; and thus, after some days confinement, the tumour becomes very much diminished, and at last may be returned.

"In some cases the application of ice also occasionally procures the return of the hernia which appeared irreducible."

The symptoms of strangulated hernia, the reduction by the taxis, and the operation as the last resource, are described in the three following chapters.

It is not our intention to attempt an abstract of a series of minute and accurate description, extremely clear and intelligible, and chiefly of that plain instructive kind which it is the business of every surgeon to store in his memory and apply to practice. The caution respecting the tobacco clyster should be carefully remembered. Mr. Cooper advises no larger a dose than one drachm of the herb infused in twelve ounces of boiling water, and even this to be used in two equal portions with the interval of half an hour between each. In justifica tion of this extreme caution he relates two fatal cases from the use, in the one case of two drachms, in the other of a single drachm. The latter produced violent pain of the abdomen, and some of the tobacco liquor appeared to find its way upwards, and was discharged by vomiting.

Mr. Cooper places much reliance on the application of ice, which however should be enclosed in a bladder so as not to keep the skin wet, as this has in one instance occasioned a mortification of part of the integuments.

Some very curious matter will be found on the subject of wounds of the intestine. In those unfortunate cases where the bowel is found partly mortified, it is the usual practice not to return it into the cavity of the abdomen, but to tie it to the outer wound, there to produce an artificial anus. It not unfre

quently happens, and several cases are here given in confirmation, that the fæces some days after the operation come away by the natural passage, and finally the wound closes and a perfect cure is effected. Where this does not happen, and the artificial anus is permanent, the situation of the patient is truly pitiable, and unfortunately cannot afterwards be

relieved.

But sometimes, instead of the gut being merely burst by the gangrenous slough forming a hole through the side

« السابقةمتابعة »