once be undertaken. By careful dissection the sac should be fully exposed, when, if the strangulation were of recent occurrence, and the sac free from inflammation and of normal appearance, an effort might be made, by gentle taxis, to secure its return into the abdominal cavity. Should adhesions bind down the sac, they might be broken up, if not too extensive; precautions being taken that all bleeding has been effectually checked before the sac is returned. If constricting bands should girdle the body of the sac and prevent its return, they should, if possible, be divided. Adhesions around the neck of the sac were to be treated with great deliberation. Having pointed out the complications and dangers to which such adhesions might give rise, he mentioned that serous effusion within the sac might be safely gotten rid of by puncturing the sac with a capillary hypodermic needle. If now the sac could not be readily reduced, he went on to say, it should be carefully opened. Unprejudiced surgeons, he thought, were at present agreed that in all those cases where it would be safe to replace the hernia by simple taxis, if that were possible, the same might be done after restraining adhesions of the sac or constricting bands around its neck had been divided with the knife. But in those cases in which the symptoms were suggestive of an aggravated condition of the bowel, and on account of which it would be dangerous to attempt to reduce it by taxis, it was necessary to open the sac. The sac having been opened, the stricture should be sought for and divided. Dr. Burchard here alluded to some points of practical interest in connection with the return of the gut; one of them was in regard to cases of deep congestion. How far the vitality of the bowel was consistent with change of color, drying of the secretions, emphysematous crackling, and fæcal odor, was a difficult matter to decide. He had seen two cases in the practice of the late Dr. James R. Wood in which a gut that was actually purple was replaced, and in both instances with the best possible results. In one case of his own, where a deep furrow marked the seat of the stricture, and where the gut itself was of a dark maroon shade, the condition of the intestine did not warrant its reposition for nearly three hours after the operation; while in another case, of more prolonged strangulation, with grave constitutional symptoms (the condition of the gut being almost identical, with the exception of the furrow or groove), the circulation was restored in one-fourth the time. He said that he could not feel that we were ever justified in returning strangulated should ment cor. al appe secure in bind d e; prec uld girl e sac wer might give duced, be rejudiced all those by simple One after around its cases in condition gerous to the sac e sought al interm was in ty of the he secre difficult e of the y purple ible re rked the a dark rant its hile in ave con almost the cir chat he gulated intestine until it gave some evidence of reanimation, while it was perfectly possible to keep it enveloped in moist flannels and rubber tissue for several hours. In cases of ulceration, it was sometimes advisable to practice partial excision before returning the intestine, and in some instances the condition did not warrant this until several hours after the operation. Extensive perforations and lacerations occurring, in herniated bowel, necessitated the formation of an artificial anus. Treatment of Adhesions.—If acute and simply binding down the body of the sac, they might be gently broken down. If they surrounded the neck of the sac, binding the intestine to the upper end of the sac, or the intestine to the cord, or to an undescended testis, it was necessary to accomplish the operation with the greatest possible gentleness and circumspection, on account of the extreme friability of the tissues. Chronic adhesions might be divided with more boldness, provided no traction were made on the inflamed intestine. In all cases the intestine, both above and below the strictured portion, should be carefully examined, after the operation. The Radical Cure.-The modern operation found its greatest advantage in the radical cure it secured by the complete closure of the sac and the permanent obliteration of the hernial canal; and it had been successfully performed upon all forms of hernia, inguinal, femoral, and umbilical, with equally satisfactory results. In the present light of hernial surgery, he thought that no operation for strangulated hernia could be said to be properly performed without the final closure of the hernial canal. By this practice five decided advantages were gained. (1) Complete isolation of the peritoneal cavity, and its permanent closure. (2) Permanent closure of the patulous orifice through which the gut escaped. (3) Shortening of an abnormally elongated hernial canal. (4) Prevention of septic percolation into the cavity of the abdomen in case suppuration should ensue. (5) The inestimable advantages that would result to the patient from a permanent cure. In the performance of the operation the clinical requirements were, first, a safe and satisfactory disposition of the sac, and, second, the total obliteration of the hernial rings, and the accurate coaptation of the sides of the canal. Disposal of the Sac.-The sac might be dealt with in one of several ways: (1) It may be reduced within the abdominal cavity, and the canal then obliterated. (2) It may be left within the canal (especially when firm adhesions prevent its safe return), and the superficial tissues and the skin be firmly approximated over it. (3) It may be ligatured, the hernial investment amputated, and the stump returned. (4) It may be ligatured and amputated, and then invaginated in the canal. (5) It may be drawn up upon itself and fixed as a bulwork against the internal ring, as in Macewan's operation. The abdominal wall may be divided longitudinally and parallel to the pillars, and the sac then woven into the fibrous structure, as suggested by Dr. Joseph D. Bryant. The first method he thought should be dismissed from consideration, except in very acute hernia, on account of the danger of causing adhesions, with their attendant pain and discomfort, or of lighting up a peritonitis. The objection to the second method was, that with the sac remaining in situ, complete obliteration of the canal could not be secured. A canal thus treated became exceedingly sensitive, and a truss could scarcely be worn. Between the remaining methods a choice could sometimes be made only after mature deliberation. Dr. Burchard said he had operated in nine cases of strangulated hernia in which he had been enabled to carry out the operation in all its details. Eight of these had recovered, and one died on the fourth day from delirum tremens. Having alluded to a number of interesting points in connection with these cases, he spoke, in conclusion, of two practical matters of importance: (1) In cases of stercoraceous vomiting and collapse, nothing had equalled in his experience, the use of hot water employed as a stomach douche, as practiced by Tait. A long, soft rubber tube was passed into the stomach, and a stream of hot water very gently injected in a continuous current. By this means the stomach was not only thoroughly washed of its fæcal contents, but the best possible stimulant in cases of hernial collapse was furnished by hot water so employed. (2) As a factor in the production of acute general peritonitis, it concealed hernias in exceptional localities where apt to be overlooked. He had met with two instances of this kind in his own experience; one being a case of bubonocele of a direct variety, and the other one of concealed femoral hernia. EDITORIAL BRIEFS. KELOID, a disease heretofore considered intractable, has been cured, in several instances, by electrolysis. DR. HEVNEAGE GIBBES, of London, England, lately appointed Professor of Pathology in the University of Michigan, will begin work in his new field in a few weeks. A GOOD FIELD.-In China and India are 400,000,000 women who have hardly a score of competent physicians to care for them. Surely a good field for the woman doctor. TEMPORARILY FILLED.-The vacancy caused by the death of Dr. Palmer, late Professor of Pathology and Practice of Medicine, and of Clinical Medicine, will be temporarily filled by Drs. Dunster, Vaughan, and Herdman. "IT IS NOT TOO LATE," says the American Lancet, "for the Medical Department of Michigan University to move to Detroit, and develop such clinical facilities as the times demand of every medical school that undertakes to educate men for practice of medicine." THE Chicago Tribune severely, but most unjustly, criticised Dr. Bridge, one of the attending physicians to Cook County Hospital, for recently refusing to treat as charity patients persons able to pay, but admitted to the hospital under political favoritism. SICKNESS OF PREGNANCY.-A correspondent in the Lancet claims not to have failed once for many years, by a single vesication over the fourth and fifth dorsal vertebrae, to put an end at once to the sickness of pregnancy for the whole remaining period of gestation, no matter at what stage he was consulted. A TERRIBLE DISEASE. -Attention has recently been called, by Governor Taylor, of Tennessee, to an incurable disease mentioned by a colored clergyman in a sermon preached on the text: "And the multitude came to him, and he healed them of divers diseases." Said he: "My dying brethren, this is a terrible text. Disease is in the world. The small-pox slays its hundreds, the cholera its thousands, and the yellow fever its tens of thousands, but in the language of the text, if you take the divers you are gone. These earthly doctors can cure the small-pox, cholera, and yellow fever, if they get there in time, but nobody but the good Lord can cure the divers." NEW TREATMENT OF CHOLERA.-Large hot injections of a solution of tannin are used by Cantani, an Italian physician, which he asserts pass the ileo-cæcal valve. It is supposed that this method stimulates the organism, by supplying the blood with fluid, by sterilizing the contents of the intestines, and by forming insoluble compounds with ptomaines. THE City Board of Health of New York, having received a communication from the Captain-General of Cuba, to the effect that small-pox was raging in Cuba, and that the supply of vaccine virus had become exhausted, referred the matter to Dr. Edson, Chief of the Bureau of Contagious Diseases, who shipped to Havana three fine, healthy, vaccinated calves for the propagation of virus. TREATMENT OF KELOID.-Guyard reports excellent results from multiple scarifications, as recommended by Vidal. The first effect is the sudden cessation of pain. In order to cure the Keloid, the scarifications must be done regularly and at fixed intervals. They should be continued till the complete disappearance of the indurated tissue; if there be recurrences, such can be similarly caused to disappear. MERCY HOSPITAL.-The annual report of Mercy Hospital, Big Rapids, Michigan, under the medical management of Dr. F. J. Groner, shows that there were five hundred and ninety-five patients received and treated during the year 1887. Many were refused admission during the year, especially female patients, from lack of room. This difficulty is now overcome by the erection of a new wing, capable of accommodating fifty patients. The hospital is free from debt and amply endowed. BETTER QUARANTINE.-The quarantine at New York succeeded in keeping out cholera; but it is not proof against small-pox, scarlet fever, or diphtheria. The inefficiency of the service has become so apparent that the New York health department requested the Mayor to appoint a committee of physicians to investigate the condition of quarantine affairs. |