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Strangulated Hernia: Reduction by the TaxisAuthor(s): Thomas HuntSource: Provincial Medical and Surgical Journal (1844-1852), Vol. 12, No. 7 (Apr. 5, 1848), pp.179-180Published by: BMJStable URL: http://www.jstor.org/stable/25500268 .

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STRANGULATED HERNIA-REDUCTION BY THE TAXIS. 19

corresponding increase in the vein above and below;

2ndly, pressure on the artery above, though it lessened,

did not wholly obliterate this swelling; 3rdly, from the

resisting nature of part of this enlargement, I was

inclined to think there was a coagulum in the areolar

tissue between the two vessels, which coagulum could

not exist if the blood was in constant mction. This is

the condition called varicose aneurisn: it is in this

collection between the two vessels, that the distinction

consists.

Another point of interest in such a caskis afforded

by the fact, (and an unfortunate one it is,) that in nine

tenths of such cases a member of the profession has

been the unintentional cause of the complaint; and

I would now take the liberty of urging upon those who

hear this case, the absolute necessity of caution in

performing so slight an operation as that of venesec

tion. Remember that the accident can be avoided

much easier than the aneurism can be cured; do not

open the median basilic vein as I did, but choose rather

the median cephalic. If the former must be opened, from any peculiarity in the case, pause one moment

before using the lancet, and place your finger over the

spot fixed upon for its point, to feel whether the artery

(as in the present instance,) be unnaturally superficial, or out of harm's way.

The other circumstance which gives some degree of

interest in this case, now that anaesthetic agents are

so greatly in vogue, and which perhaps, from all I read, would render it almost unique in the surgical annals

of the existing age, was the total failure of chloroform

not only failure, but (from its producing excitement,)

injury and impediment in the proceeding. We might theorize and speculate as to the cause of this,-whether

extreme cold prevented ready evaporation from the

handkerchief,--whether the inhalation of it not being

agreeable to the patient, he obstinately closed his

mouth against it,-or whether idiosyncracy of consti

tution rendered him insensible to its excellent agency.

Certainly the quantity was more than should have'i

sufficed, the drug was good, and the means adopted for

its effect, were similar to those tried by others.

STRANGULATED HERNIA: REDUCTION BY

THE TAXIS. TO THE EDITOR OF THE PROVINCIAL MEDICAL AND

SURGICAL JOURNAL.

SIR, I feel it incumbent upon me to offer my unfeigned

thanks to Dr. Paxton, ofRugby, for his prompt and

candid confirmation of my views of the general success

of the patient employment of the taxis in strangulated hernia. In truth, I felt more diffidence than I thought

proper to express, in publishing my experience. It is by no means a pleasant task to impugn the prevailing practice of our brethren, and nothing but an urgent sense of duty

would have impelled me to do so. Allow me, however, to say, that hospital practice in hernia is too generally

attended with peculiar difficulties. Before the admission

of the patient the taxis has often been repeatedly tried, and the case has become complicated with symptoms of

inflammation or approaching gangrene, and in these cir

cumstances I should be the last to condemn a reluctant

operation. The forlorn hope may jnstify it. But as

regards recent cases, (often rendered eventually hopeless

byinjudicious manipulation,) Ido believe that the efficiency of the taxis, rightly performed, cannot be too frequently urged upon the profession.

Perhaps an illustrative case or two may produce more

impression than reiterated precepts. CASE 1.--My attention was first awakened to the right

use of the taxis many years ago. I was called to a case

of inguinal hernia in a robust, vigorous boy, about two

years of age, a farmer's son. The hernial tumour had

been discovered about thirty hours, but how much longer' it had existed could not be ascertained. Having tried the.

taxis about twenty minutes without success, I began to

think seriously of the operation; but the child was.

strong, and unusually obstreperous. I reflected that at a

lone farm-house I should find much difficulty in getting the child effectually controlled, and having then no

assistant, and there being no surgical assistance at hand, I confess the difEculties attending so delicate an operation began to assume a formidable character. I therefore

reflected, that as no signs of inflammation were present, and the case was favourable for reduction, it ought to

be reduced, and accordingly I resolved that it should be

done,-and allow me to add, that in such a case resolution

is half the battle. I placed the patient on a table, with a mattress and pillow, of convenient height, on his

back, with his legs bent, and the limb of the affected

side directed over the other, and taking my seat on a high

chair, so as to command the best use of my arms and

hands, I commenced, steady, gentle, and gradually increasing pressure on all sides of the tumour, and in an

hour and three quarters, just as my strength was begin

ning to fail, I had the satisfaction of perceiving an evident

decrease in its size, and in a few minutes heard the

gurgling noise which preceded its return into the abdomen.

CASE II.-About two years ago, I was called late at

fight to a case of strangulated inguinal hernia, in a

carpenter, aged 60, who had formerly worn a truss, but

having broken the spring, believed the rupture cured.

The tumour had existed fourteen hours; it filled and dis

tended the scrotum; it was twenty-five inches in circum

ference, and of course could only be partially covered by both my hands; it was tender, as well as the abdomen;

and nausea, quick pulse, and sunken features, proclaimed the urgency of the case. The patient was laid on his

back in bed, the muscles relaxed, and placing myself on

my knees, supported by a pillow, I compressed the

tumour with both hands, as one might squeeze a mop. In half an hour my hands were both paralysed, and no

apparent result obtained. I then sent for my assistant, who took my place; meanwhile I supplied myself with

O'Beirn's defecation tube, as the next best resourse, if

the taxis should fail, and also some tartar-emetic. My assistant was tired in his turn; I resumed my laborious

post, and in two hours from the commencement of the

pressure, the tumour was evidently softer and smaller.

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180 THE TAXIS.

The reduction was soon afterwards accomplished, and the

patient had not one bad symptom.

I have selected these two cases from a large number as

illustrative of the method, and can add nothing in favour

of its success more convincing than the results. I trust

many members of the Association have met with similar

cases, and I entreat them to come forward and support a

mode of treatment which I think no honest intelligent

surgeon can condemn.

I am, Sir, yours faithfully and obliged,

THOMAS HUNT. Herne Bay, March 14, 1848.

THE TAXIS.

TO THY EDITOR OF THE PROVINCIAL MEDICAL AND

SURGICAL JOURNAL.

SIR,

On Saturday, the 12th of February last, I was reading Mr. Hunt's letter, dated Herne Bay, December 18th, 1847, "On the Taxis in Strangulated Hernia," and

before I had finished it I was sent for to a most alarming

case of strangulated hernia, in a woman, of the name of

Sarah Mapp, about seventy years old, of Clow's Top, about five miles distant from this town. The descent, which was on the left side, took place on the previous

Tuesday, while she was opening a door which required some exertion. As was usual with her, when it de

scended and became painful, she placed herself in the

proper recumbent posture, and always, till now, effected the reduction. The first descent occurred

nearly twenty years ago, at or about her last labour.

She was now foiled, for the probability is, that the

incarceration commenced at the moment of its descent.

The excruciating pains about the praecordia, and

strictured parts, the sickness, and vomiting, soon

induced her to send for me that day. I found her in

great agony, the hernia very hard and painful, with

constant sickness and vomiting, tenderness of the

whole abdomen, peculiar pain and constriction about

the diaphragm and stomach, and costiveness. The

hernia would hardly bear the least pressure; however, I tried the taxis ineffectually for nearly two hours, with

my patient in the most favourable position. I gave her

opium and calomel, with the saline camphorated mixture.

In the morning I saw her again; the same train of

symptoms existed, with hiccup in addition, all the day; and on the following morning I proposed the operation

by the knife, and that Mr. Davis, of Tenbury, should

meet me that evening, or early the next morning. This was not agreed to, and two gentlemen were sent for from Bewdley, on Friday, without my knowledge.

They tried the taxis for upwards of two hours, using, as the patient and attendants informed me, very great force, so that her groans and shrieks were truly terrific. All their efforts, however, to relieve her

proved unavailing, and they left her, consigning her

to inevitable death in two or three days at farthest, unless the knife was resorted to, and to this she

declared she would never consent.

On Saturday I was again summoned to her, while I

was reading Mr. Hunt's letter, which made so forcible

an impression on me, that after re-reading it, I hastened

to my patient, persuaded of the true philosophy of

Mr. Hunt's reasoning, as it explained to me why I

had succeeded in a case which was fresh in my

recollection, and which I will advert to presently. On

reaching the house I found the woman with every

symptom aggravated, and the abdomen very tympanitic, and every appearance of the near approach of morti

fication, which I concluded was inevitable, particu

larly on hearing of the force employed the day before. The hernia was so exquisitely tender, that I

had the greatest difficulty to persuade her to permit me even to touch it; at last I prevailed, and com

menced very gently, " not by pushing, and kneading, and thumbing, but by gentle equable compression on

all sides of the tumour, the abdominal and psoas muscles being previously relaxed," so as gradually to empty the distended veins; and I was determined

to proceed, confident of effecting the return of the

contents of the sac, though I had every reason to

anticipate mortification, as before observed. After

the lapse of an hour and a half, she ceased moaning; the sickness and hiccup abated, and the hernia was

softer, and soon after I felt a motion in it, and in

another hour reduction was affected. I now ad

ministered an enema, which went up easily, and

remained about five minutes, and returned uncoloured, but before half an hour she had three large faeculent

motions, with a considerable discharge of flatus.

It would occasion unnecessary waste of your valuable

space, if I were to detail the subsequent treatment,

which was very simple; suffice it to say, that the

hiccup and sickness soon entirely left her, but the

abdominal tenderness remained about a fortnight, and

she is now restored to her usual state.

The case to which I promised to advert is the

following :

Mrs. Wheeler, an inhabitant of.this town, died about

two years ago, in her 93rd year. She was a patient of

mine about 30 years, and was subject to a femoral

hernia exactly similar to Mrs. Mapp's, during the

whole time,. except that she frequently required my assistance. Owing to her negligence in the use of

her truss, and some peculiarity, the hernia was often

incarcerated, and she had considerable difficulty in re

ducing it herself, and would frequently postpone calling me in, till pain and sickness compelled her, which was

two, three, and sometimes four times a year. Before

effecting reduction by the taxis, two hours' constant,

gentle, and equable pressure were always required, and I invariably observed a motion in the tumour

some time prior.

I have seen in subjects of different ages, and some

times in young boys, very serious cases of paraphymo

sis, but I never met with one irreducible, by adopting the means recommended by Mr. Hunt in the taxis.

In these cases we know that it is by gentle and steady

pressure of the glans, so as to evacuate its blood-vessels, that the favourable result is accomplished.

I remain, Sir, yours respectfully, THOMAS POPE.

Cleobury Mortimer, March 17, 1848.

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