"




Colop NAL REPORTASSO'n.
ColoFINAL
OF THE
COMMITTEE
OF THE
PHILADELPHIA MEDICAL SOCIETY
ON THE
CONSTRUCTION OF INSTRUMENTS,
AND
THEIR MODE OF ACTION,
IN THE
RADICAL CURE OF HERNIA;
(FROM THREE YEARS' OBSERVATION;)
ACCOMPANIED BY A COLLATION OF THE PRACTICAL FACTS
CONTAINED IN THE
PRELIMINARY REPORT:
WITH
NOTES, ILLUSTRATIONS, AND ADDITIONAL CASES OF HERNIA,
AND
DISEASES RESEMBLING HERNIA:
ALSO
ILLUSTRATIONS OF CERTAIN INSTRUMENTS DESIGNED FOR THE TREATMENT
OF OTHER DISEASES EFFECTING SIMILAR PARTS.
BY HEBER CHASE, M. D.
MEMBER OF THE ACADEMY OF NATURAL SCIENCES, HONORARY MEMBER OF THE
PHILADELPHIA MEDICAL SOCIETY, ETC.
There is no reason to despair of being able, one day, of effecting a radical cure in
most cases of Hernia.-TAVERNIER.
PHILADELPHIA:
PUBLISHED BY J. G. AUNER.
1837.
51

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LIBRARY STREET.
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121
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25-Sept. 16.
1024
78403
0507

CMLA
61634
238
T881 is Bh
"Fully impressed with the extreme caution required
in forming conclusions concerning changes of structure
taking place in parts of the body concealed, not only
by the integuments, but by tendinous matter and fascia,
and where the nature of the disease renders the oppor-
tunity of post-mortem examination exceedingly rare,
your Committee has been desirous of avoiding that
blameable haste in the decision of important questions
which has too frequently given to plausible, but inge-
nious methods of treatment, a temporary reputation,
to the abuse of public confidence, and the injury of the
profession, by granting to empyricism the weight and
influence of great names."-Preliminary Report.por of
nonoma odi ni simoll to or [sotball out no estim
zoongig? InstaM on to Tourvel
CMLA 363

At a meeting of the Philadelphia Medical Society held
April 29th, 1837,
borib
CYLLE
monizo ad din hosvotemi vllu P
Dr. R. COATES completed the reading of the Report
of the Committee on the Radical Cure of Hernia,
when, on motion, auonibnot vd tud at sini off पूर्व
reggo eft abror par er
Resolved, That the same be accepted and the Com-
mittee be discharged, and that the thanks of the So-
ciety be tendered to the Committee for the able and
elaborate manner in which they have attended to the
duties of their appointment. sou lo abediers aro
adi To
dug lo sands of of
Resolved, That a Committee of Two be appointed
to request the publication of the Report of the Com-
mittee on the Radical Cure of Hernia in the American
Journal of the Medical Sciences.
obil
EJE

TO
MY FATHER
THE FOLLOWING PAGES
ARE
DEDICATED,
WITH FEELINGS WHICH NEED NOT BE EXPRESSED,
BY HIS
AFFECTIONATE SON,
THE AUTHOR.

0
e3925 ONTWORT SITT

i bes
no one lo vam
sw no
Ano
ei oli
dong
Hindi olid grool ruumi.Ti
odi ai botas
4.
breybu
nol
pisut
mue taroch
bkrople to
borobust
Troteid of
miamo
oda o od
01
TO THE READER.
adr
do eno
To motreg 98
ubo yd boift ers
THE appearance of the following pages seems to
demand some apology, after the publication of the two
able Reports of the Committee on Hernia, appointed
by the Philadelphia Medical Society in 1834, whose
attention has been so long and so laboriously directed
to the investigation of the action and construction of
the instruments which are described in the body of this
work.
# 90111
in ein ode
It may be considered as an assumption on the part
of the inventor of the apparatus which has had the
good fortune to receive the decided approval of that
Committee, that he has ventured to add to the testi-
mony of such judges some notes, explanations, and
additional cases from the results of his own experience.
But there are extenuating circumstances, which, it is
hoped, will be deemed a sufficient excuse for the course
which I have taken.
Sar eru
The two publications of the Committee are separated
by an interval of more than a year; they appeared in
a strictly professional journal, and were consequently
circulated almost exclusively among medical men. The

viii
TO THE READER.
narrative of many of these cases was commenced in
the Preliminary Report, while their conclusion was
presented in the Final Report. This arrangement,
though sufficiently convenient for those whose life is,
or should be one round of laborious study and research,
rendered it difficult for less practised inquirers to trace
the history of the facts upon which the opinions of the
Committee were grounded; and as a large portion of
those who are affected with hernia are fitted by edu-
cation and intelligence to estimate the value of these
Reports, which are not less distinguished by their clear-
ness and simplicity than by their rigid caution and pro-
fundity of thought, it was considered highly desirable
that the whole subject should be presented to the popu-
lar reader in the most accessible form. For this pur-
pose, the details of the cases contained in the Prelimi-
nary Report have been prefixed to the continuation of
the same cases in the Appendix to the Final Report,
and many extracts from the former document have
been appended, in the form of notes, to the latter more
elaborate paper; so that the whole subject is presented
to the reader in the form most convenient for reference,
not only to the general inquirer, but even to the surgeon.
Do adoper out
Untiring as was the attention of the Committee,
there were many causes which rendered it impossible
for them to visit, or for me to bring before them all
the cases of importance which came under my notice
during the three years of investigation; and as the
Committee, with a degree of conscientiousness worthy
of all praise, confined their record of facts to those
cases personally observed by themselves, and their

TO THE READER.
ix
inferences from those facts, the public has not yet re-
ceived all the evidence which may be regarded as inte-
resting: I have ventured, therefore, to continue in the
Appendix details of a few of these cases, extracted from
my note book.
The Committee have most scrupulously avoided the
discussion of all debatable opinions in the course of
their labours; but as some of these questions have a
practical bearing of great value, I have addressed
several notes to the Chairman of the Committee at
different times, requesting his individual views on some
of these subjects: to all which inquiries he has replied
with frankness, and in a manner suited to the import-
ance of the question. His letter on the modus ope-
randi of trusses in effecting the radical cure of hernia,
(almost a treatise in itself,) was published in my work
on Hernia, p. 107. Some extracts from this letter,
and two other communications which illustrate or
carry out the views of the Committee, will be found
among the notes appended to the Report.
No liberties have been taken with any part of the
text derived from the Committee, and every note not
extracted from the Preliminary Report is marked with
the initials of the person on whose authority it is given.
As varicocele is a disease bearing some little resem-
blance to hernia in its external appearance, and as it
is not unfrequently mistaken for the latter even by
medical practitioners, my attention has been drawn
particularly to this complaint by the number of cases
1*

TO THE READER.
X
presenting themselves while wearing trusses for the
relief of a tumour which is always rendered worse by
the use of such instruments: and having found varico-
cele difficult to manage by any plan of treatment now
in use, I have added to the present publication a de-
scription and figure of a new suspensory for the relief
of the very unpleasant symptoms produced by this
affection. It has succeeded not only in giving relief,
but even in effecting cures, to an extent beyond any
anticipation entertained at the time of its construction.
The numerous cases of uterine affections and va-
ginal disease occurring in females who have placed
themselves under my charge for the cure of hernia,
or who have been brought to me by some of their
friends while under treatment, has induced me to at-
tempt an improvement in the syringe designed for va-
ginal injections. The description and figure of my
instrument for this purpose conclude the work: they
are extracted from a paper previously published in the
American Journal of the Medical Sciences, and are
now thrown before the profession and the public for
the purpose of introducing an addition to the ordinary
surgical apparatus, which has been found highly ser-
viceable in my hands.
The most difficult part of my task remains to be
performed the expression of my deep obligation to
the gentlemen of the Committee on Hernia for the very
unusual labour and time which they have devoted to
the investigation of my herniary apparatus.

TO THE READER.
XI
Had the Committee been influenced by feelings which
are natural as well as general in all places where com-
petition is carried to extremes, and in all professions,
when over-crowded with aspirants, they might have
performed their duties with credit, and as such duties
are usually performed; but not with the vigour of re-
search, the long and patient observation, and the entire
publicity required to render their opinions available in
enabling me to cope with the prejudices and heavy in-
terests combined against this innovation-an innova-
tion which tended to destroy a profitable and extensive
business, by taking the treatment of hernia by trusses
from the hands of the instrument-maker to place it in
those of the surgeon.
Of the many kindnesses and useful hints received
from the Chairman especially, whether in his official or
individual capacity, it is difficult to speak in terms suited
to the occasion. This obligation is not the less keenly
felt, because this gentleman is distinguished as a severe
critic and unbending judge-one who allows no private
friendship or personal influence to warp his opinions
or suppress the expression of them, when the good of
humanity or the defence of a principle is at stake-
one who, when called upon to express an opinion on a
professional point, does not pause to inquire how his
answer may affect this man's wishes or that man's repu-
tation, but has been ever ready to sacrifice his own
feelings and interests for the public good.
The Final Report of the Committee is a model for
this kind of essay: it is at once clear, unpretending

xii
TO THE READER.
and profound, being one of the happiest efforts of a
pen well known to the profession, as almost replacing
the pencil, when called to the discussion of complex
mechanical questions, and which shrinks not from a
physiological argument, however involved in its rami-
fications. I know that the writer will forgive me when
I proclaim it one of my proudest triumphs to have
convinced him by the force of facts, in opposition to
his firm persuasion, that it was possible to effect the
perfect retention and consequent cure of hernia by
mechanical means alone.
To the medical profession generally, I tender my
sincere thanks for the manner in which they have no-
ticed my efforts to improve the treatment of a most
distressing and too frequently fatal disease; and those
gentlemen who have employed the novel instruments
in various parts of the United States and elsewhere,
many of whom have communicated valuable remarks
on their action and their results, will oblige me by re-
ceiving this public testimonial of my warm acknow-
ledgements.

CONTENTS.
Address to the Reader,
FINAL REPORT OF COMMITTEE ON HERNIA,
Preliminary remarks,
Classification of Trusses with Solid Blocks,
Trusses of the first class designed to produce irritation,
Trusses of Stagner, Hood, Price and Semple,
Trusses of the second class not designed to produce ir-
ritation, .
Eberle's, or the Rachet Truss,
Chase's Trusses,
Argument against the doctrine of cure by adhesive inflam-
mation,
Physiological effects of the Trusses of the first class,
Perfect Retention the cause of cure by Trusses,
Examination of the retentive power of the different Trusses
of the first class,
Trusses with Conoidal Blocks,
Eberle's, or the Rachet Truss,
Apparatus of Stagner and Hood,
Claims of Stagner and Hood,
Disapproval of the complex apparatus of Hood,
Umbilical Block of Hood,
•
•
·
Femoral Block of Hood,
Inguinal Block of Stagner and Hood,
Ventro-inguinal Blocks of Hood,
Claims of Dr. Hood as to the manner of application,
Conclusions against Trusses of the first class,
·
Page
7
17
ib.
22
ib.
23
24
ib.
25
26
32
34
35
ib.
ib.
37
ib.
ib.
39
ib.
41
43
45
46

xiv
CONTENTS.
Examination of the retentive power of the second class,
Principle of the action of Dr. Chase's Trusses,
List of the instruments of Dr. Chase,
Description and analysis of the retentive power of Chase's
•
Trusses, .
Chase's Common Inguinal Truss,
Of the Block,
Of the Block Attachment,
Of the Spring and Strap Attachment,
Letter of Dr. R. Coates on an improved Spring, (Note,)
Of the Appendages,
Approval of this instrument,
Chase's Ventro-inguinal Truss,
Estimate of the danger of accident from this instrument,
Approval of this instrument,
Chase's Femoral Truss,
·
·
•
•
Entire novelty of this instrument,
Of the Block,
Of the Block Attachment,
Chase's Double Truss,
Warm approval of this instrument,
Chase's Umbilical Truss,
Of the Block and Attachment,
Approval of this instrument,
Of Chase's Umbilical Belt,
Disapproval of this instrument,
Importance of wearing Trusses continually,
Bathing Trusses,
Conclusion in favour of the high retentive power of the Trusses
of the second class,
Extract from Dr. R. Coates' letter on the modus operandi,
Physical effects of Chase's Trusses,
Of degree of superficial irritation,
Of the sub-cutaneous absorption,
Of the contraction of the ring,
Changes in the margin of the ring,
Of the contraction of the ring to less than its natural di-
mensions,
•
Page
ib.
47 49
50
ib.
ib.
51
52
55
58
60
61
64
66
SOFRERARRASA
71
74
ib.
ib.
ib.
ib.
ib.
ib.
ib.

CONTENTS.
Disconnection between irritation and the changes in the
ring,
Causes of the contraction,
Changes in the sac,
Occlusion of the neck of the sac not necessary for cure,
Conclusion of the Committee on the claims of Trusses
of the second class,
Recommendation of Chase's Trusses as means of reten-
.
•
tion,
What constitutes a radical cure?
Vices of formation predisposing to hernia,
Question of danger of consecutive hernia from the use of
·
Trusses, .
Disapproval of the use of Trusses as a prophylactic mea-
sure,
Occurrence of hernia in other parts no disproof of radi-
cal cure,
Recurrence of hernia not always a disproof of radical
cure,
Some cases are more secure after the treatment than they
were before the accident,
Definition of radical cure,
Tests of radical cure,
Results of the practical observations of the Committee,
Conclusions on the power of Chase's Trusses to effect
radical cure,
Objections to the use of Trusses for small children in
the Preliminary Report recalled by the Committee,
Time required for radical cure,
Thirty cases reported by Committee,
Remarks of Dr. R. Coates on Case XXX.,
.
.
•
•
Hydrocele, (Case,)
Hydrocele of the cord, (Case,)
Enlargement of the cord, (Case,)
XV
.
Page
86
ib.
87
ib.
88
90
91
ib.
ib.
92
93
ib.
94
ib.
ib.
95
101
175
DR. CHASE'S REMARKS ON DISEASES MISTAKEN FOR HERNIA,
185
Varicocele or Cirsocele,
ib.
Glandular swellings in the groin, (Case,)
188
Femoral hernia mistaken for glandular swelling, (Case,) 190
ib.
191
192
97
98
99

xvi
CONTENTS.
Page
Ventro-inguinal Hernia mistaken for Hydrocele, (Case,) 193
Varicocele mistaken for Hernia, (Case,)
194
196
Inflamed Inguinal Gland mistaken for Hernia, (Case,)
Varicocele mistaken for Hernia, (Case,)
199
201
ib.
On delayed descent of the Testicle,
Descent of Testicle delayed for eighteen years, (Case,)
Late descent of Testicle. Hernia and Testicle both re-
duced, and the disease radically cured, (Case,)
Hernia treated before the descent of Testicle, (Case,)
Testicle in the canal mistaken for Hernia, (Case,)
Accidental reduction of Testicle with Hernia, (Case,)
TABULAR STATEMENT OF 200 CASES OF HERNIA,
ON CIRSOCELE OR VARICOCELE,
Description of Chase's Suspensory,
Proposed means of cure of Varicocele by operations,
Compression,
Ligature of the Spermatic Veins,
Ligature of the Spermatic Artery,
Excision or extirpation of the Spermatic Veins,
Removal of the Testicle,
.
Remarks on these operations,
Remarks on the use of the Suspensory, with notes of
cases,
An account of an improved Vaginal Syringe,
.
202
205
ib.
207
208
217
223
228
ib.
229
230
231
ib.
232
233
240

09
po
REPORT
ON THE
to
RADICAL CURE OF HERNIA.
The Committee appointed by the Philadelphia Medical
Society, at the session of the 27th of December, 1834,
with directions to investigate the character of STAGNER'S
TRUSS, and other proposed means of radical cure of
Hernia, respectfully
*
BAG REPORT:
That since the date of their Preliminary Report,
(read Dec. 5th and 12th, 1835,) they have devoted
much time and thought to the important investigation
submitted to their charge; but the numerous mooted
questions originally involved with it, have been gra-
* The claim of Mr. Stagner extends only to the truss armed with
a wooden block similar to that which is called the Inguinal block
of Dr. Hood; and as this was condemned in the Preliminary Report
of the Committee, (see p. 310-323,) the Final Report contains scarce
any
allusion to the truss of Mr. Stagner. It is chiefly in the head-
ing, which is extracted from the minute of the appointment of the
Committee, that reference to that instrument appears in the later
proceedings of the Committee.
H. C.
2

18
REPORT ON HERNIA.
dually narrowed down in number and compass, in three
different ways; firstly, by the decision of several phy-
siological points; secondly, by the results of the ana-
lysis of the mechanical construction of instruments;
and thirdly, by the introduction of improvements in the
formation of trusses, calculated to remove the objec-
tions waged against some portion of the apparatus
represented as imperfect in the Preliminary Report.
In offering to the society the conclusions deduced
from the observations of the Committee, it is deemed
unnecessary to enter at length into all the evidence upon
which those conclusions have been founded, for much of
this matter is already before the public in a form suffi-
ciently authentic, and accessible for every useful pur-
pose; and the attempt to include the whole, would
swell this report beyond all reasonable or necessary
limits. Reference will, therefore, be freely made to the
following documents, which have been produced and
published in consequence of the investigations of the
Committee: 1st. The Preliminary Report, published in
the American Journal of the Medical Sciences, Vol.
XVII. p. 307. 2nd. Note of R. COATES, M. D., on
two new Hernial Blocks. Ibid. 543. 3d. Letter from
the same gentleman to HEBER CHASE, M. D.,* in reply
At the time of the appearance of the Preliminary Report, the
author of this work was pursuing his studies in the University of
Pennsylvania, under the auspices of which institution he afterwards
received the degree of Doctor of Medicine. This will explain the
employment of the title of Mr. prefixed to his name in the Prelimi-
nary Report, and that of M. D. appended in the Final Report.
R. C.

REPORT ON HERNIA.
19
to a note of the latter, on the modus operandi of instru-
ments in Dr. CHASE'S Treatise on the Radical Cure of
Hernia by instruments. Philadelphia, 1836.
912
Reference will be also made occasionally to the me-
chanical reasonings and the detailed cases contained
in the work just mentioned.
In the eighth section of the Preliminary Report, (Op.
cit. p. 324,) the Committee ventured upon a physio-
logical disquisition on the modus operandi of trusses,
in producing the apparently radical cure of Hernia; and
their conclusion on this subject was presented in the
following sentence.
"These positions will explain the motive of the Com-
mittee in taking the ground, that the most perfectly
retentive apparatus is that which offers the strongest
probability of radical cure, and that any considerable
irritation produced in the parts by the pressure of a
block, may be considered, in the present state of the
investigation, of secondary importance."-p. 326.
In the letter of the Chairman to Dr. HEBER CHASE,
to which reference has been already made, the question
of the modus operandi has been argued at greater
length than would have been proper in a report designed
to present a rigid detail of facts and established de-
ductions; but the tenor of that letter, written after much
more extended observation than had been offered when
the report was read, adds collateral support to the pre-
sent opinions of the Committee, founded upon the whole

.20
REPORT ON HERNIA:
of the evidence before them; namely, that the radical
cure of hernia, by trusses, depends almost exclusively,
if not entirely, upon the accuracy and permanency of
the retention effected by the instrument. That, con-
siderable or long continued irritation in the parts, so far
from being an advantage, in reality opposes the suc-
cessful treatment; that there are no facts in their pos-
session which tend to prove indisputably that even
slight irritations of the superficial tissues are transmit-
ted to the tendons of the abdominal muscles in such a
manner as to accelerate the cure; and that radical
cures are sometimes effected without any other irrita-
tions than such as are altogether fugitive in character.
It will be remembered by the Society that the Com-
mittee, in the Preliminary Report, expressed the de-
cided opinion that "the retentive power of solid blocks
exceeds, cæteris paribus, by considerable difference, that
of pads composed of softer materials."*
The whole current of the evidence since presented
to them, most fully substantiates the correctness of this
position, as the number of cases has been large in which
the various instruments with soft pads have failed in
* "The Committee are decided in the opinion, that the retentive
power of solid blocks exceeds, cæteris paribus, by considerable dif-
ference, that of pads composed of softer materials. If there could
be any exception taken to this rule, it would be in favour of pads
formed of very firm but highly elastic materials; but the only sub-
stance of the latter character now employed in the construction of
truss-pads, is the gum-elastic; and against the direct application of
caoutchouc to the skin, there are strong physiological objections."
-Preliminary Report.
CMLA 363
Colo. Med. Lib' Asso'n.

21
effecting accurate and permanent retention, and in
which the more perfect apparatus with.blocks of proper
form have been substituted with complete success.
REPORT ON HERNIA.
It has been deemed unnecessary to preserve volumi-
nous records of the multitude of cases presented, at
different times, before the individuals comprising the
Committee, which proved the superior retentive powers
of the trusses with solid blocks, but which could not be
subjected to frequent examination, on account of the
fastidiousness of patients, or the distance of their resi-
dences; but sufficient evidence on this head will be
found among the detailed observations appended to the
former and the present reports. Nor is it esteemed
desirable to burden the Society with a laboured ana-
lysis of the mechanical defects in the form, material,
and mode of attachment presented by the several de-
scriptions of trusses in use prior to the introduction of
the contrivance of Mr. Stagner; defects in nearly every
instance removed by more recent improvements. This
subject has been ably discussed in the fourth chapter
of Dr. CHASE's work. The problems involved in it are
chiefly of a mechanical character, and all members of
the profession who are at all familiar with the exact
sciences are therefore equally competent judges of the
correctness of the demonstrations. There has been no
evidence presented to lead the Committee into any
change of opinion as to the impropriety of substituting
firm but elastic materials for the absolute solids in the
construction of the armature of trusses. The employ-
ment of caoutchouc (of which truss-pads are sometimes
constructed) as a direct and permanent application to

REPORT ON HERNIA.
Ede
22
the skin, has been fully proved to be altogether inad-
missible. The proofs of this fact were thrown before
the society in a recent lecture, a notice of which will
be found in the American Journal of Medical Sciences,
Vol. XIX. p. 550; and the Committee will merely add
that the irritating effects of this substance are so well
known in the neighbourhood of the caoutchouc cloth
manufactory, near this city, that it is extensively em-
ployed there as a popular remedy in cases of chronic
rheumatism.*
nose/ did boM
These remarks have been premised, in order to ex-
plain the motives of the Committee in confining their
report exclusively to the consideration of the action of
trusses with solid blocks in place of pads. Their ob-
servation has been extended over a much wider field,
but they deem it inexpedient to occupy the time of the
Society with an account of the defects of various ap-
paratus which have been so fully analyzed by others
that the merits and demerits may now be considered
as fairly before the public.
The trusses with solid blocks, now in use or recom-
mended by inventors, may be divided into two classes.
* See also a paper in the Southern Medical and Surgical Jour-
nal, Vol. I. p. 663, "on the physiological effects of caoutchouc
as an endermic application for the purpose of counter-irritation.
Read before the Philadelphia Medical Society, Nov. 1836, by Heber
Chase, M. D."
We agree with Dr. CHASE in condemning the India rubber or
gum-elastic, as a substance entirely inapplicable for this purpose.
We have seen a case where it produced not only a blister but an
ulcer."-Southern Med. and Surg. Journal, Vol. I. No. 8, p. 471.
H. C.

REPORT ON HERNIA.
23
1st. Those which are constructed for the express pur-
pose of producing irritation, in order to effect a con-
densation of the skin, cellular tissue, and the fascia
superficialis or the abdominal tendons about the hernial
orifice, into one common mass by adhesion. 2nd.
Those which are designed to secure the constant, per-
fect and safe retention of the bowel, without the at-
tempt to create intentional irritation in the parts
pressed by the instrument.
The first class includes the truss of Stagner, and
the various apparatus of Dr. Hood for the treatment
of common inguinal, ventro-inguinal, femoral and um-
bilical hernia.
Your Committee are not assured whether the several
conoidal truss-blocks of lead, tin, or other metals, of
which that attached to the strap and buckler known as
Price's Truss (figures of which are seen in figs. 1, 2,
3, 4,) may be taken as the type, and the truss which
bears the name of Sample's patent, as the least objec-
tionable, were intended or not, by their inventors, to
produce adhesions between the skin and parts beneath;
but as they undoubtedly act in a manner better calcu-
lated to produce irritation than either of the other
forms, they are most naturally arranged in this class.*
* "We
presume that the intention of this pad is to produce irri-
tation, and adhesive inflammation." Journal of the Franklin In-
stitute, Vol. XV. No. 5. p. 336.
Lawrence's truss, of Kentucky, Thompson's and Wadsworth's
of Vermont, and several others act in the same manner and are
applied upon the same principle.-H. C.

24
REPORT ON HERNIA.
THE LEADEN CONOIDIC BLOCK AND STRAP.
2
0
D
1
4
a
Ø
d
D
D
C
C
3
SET
FIG. 1.- A mass of lead of a conoidic form.
b The pelvic strap.
cc The buckles for securing the pelvic strap.
d The buckle for the perineal strap.
FIG. 2.-A longitudinal section of the lead, perpendicular to the base.
FIG. 3.-A transverse section perpendicular to the base.
FIG. 4.-A full view of the base and screws.-The strap and buckles
detached.
The second class contains the old and well known
instrument introduced to the notice of the Society by
Dr. PERRINE, during the debate which followed the pre-
sentation of the Preliminary Report in 1835.
This instrument, known under the name of Eberle's,
or the Rachet Truss, was alluded to in the report,
when ivory truss-blocks were mentioned; but the
specimen presented to the society by Dr. PERRINE was
armed by a wooden block; and although the Commit-

REPORT ON HERNIA.
25
tee were not previously assured that wood had been
employed in the construction of truss-blocks prior to
its employment by Mr. Stagner, they have since ascer-
tained that it has been in use for twenty years, and
probably for a much longer period.
THE OLD WOODEN BLOCK OF EBERLE.
Ка
a
9
6
b
h
5
C
d
Oc
b
K
一层
​CO
FIG. 5.-a The old fashioned wooden block of EBERLE's truss.
b The iron block-rider or plate.
cc Screws attaching the block-plate to the wood.
d The rachet.
e The rachet-wheel.
f The iron neck of the wheel.
The main-spring.
g
h The pelvic strap-button.
k The perineal strap-button.
FIG. 6.-Longitudinal section of the truss-block of EBERLE's truss-
The letters having the same references as in fig. 5.
This class also embraces all the instruments invent-
ed by Dr. CHASE, which are five in number, and will be
spoken of in detail hereafter.
The remarks of the Committee on the first of these
3

26
REPORT ON HERNIA.
classes, naturally arrange themselves under two heads.
1st. Comments upon the supposed establishment of
adhesive inflammation; and 2ndly. An estimate of the
retentive power of the apparatus.
First then, on the establishment of adhesive inflam-
mation by trusses of the first class. Your Committee
have watched, with great caution and most minutely,
the changes produced by the pressure of the truss-
blocks in a number of cases; and the result of their
observations may be summed up as follows: The ap-
plication of the instrument soon produces an erythe-
matous blush of the integuments, which, when the
pressure is severe, often continues for weeks or months;
but, when mild from the first, or rendered so at a later
period by the substitution of an instrument with a
weaker spring, the redness of the skin changes its
character, and appears, on the removal of the instru-
ment, like that simple result of capillary distension
which is witnessed immediately on the removal of a
tight bandage, wherever it may have been applied; a
distension obviously produced by diminished action of
the arcuated fibres and coats of the vessels, the tonic
contraction of which has been rendered unnecessary
for a time by the substitution of a mechanical support,
the capillaries being thus incapacitated for resisting
completely the vis a tergo of the arterial circulation
and the hydrodinamic pressure of the venous column.
This cause being more permanent during the use of
the truss than during that of almost any ordinary
bandage, the consequences are also more durable; and
this second kind of redness, or purpleness, is some-

REPORT ON HERNIA.
27
times observable for many days after the removal of
the instrument.
The first of these forms of redness is the obvious
effect of the superficial irritation produced by the pres-
sure of the block, and may be called, with some pro-
priety, the primary redness; the second is seen even
after the parts have become accustomed to the presence
of the instrument, and we shall take the liberty of call-
ing it the secondary redness.
The form of hyperemia observed in the primary red-
ness is known to be favourable to adhesion, if the irri-
tation be not sufficiently intense to produce decided
inflammation; and even when inflammation does super-
vene, if the constitution of the patient be good, the
inflamed part will be surrounded by cellular adhesions,
or depositions usually so called, designed to limit its
progress, according to a well known physiological
law.
The primary redness, during the use of the trusses
of the first class, is often carried to such an excess as
to produce decided inflammation, and sometimes even
excoriation of the skin. (Case X.) It becomes, then,
a question of considerable importance to decide
whether the irritation of the block, or that produced
by the inflammation which it sometimes causes, ever
be transmitted to deeper seated parts so as to bring
about adhesion between the cutis vera, the subcutane-
ous cellular tissue, and the fascia superficialis. The
conclusion on this point will be stated presently.

28
REPORT ON HERNIA.
The form of hyperemia as seen in the secondary
redness, marks a condition of the vessels, which, in-
stead of promoting adhesion, is well known to retard
the formation of false membranes, while it promotes
absorption to such a degree as frequently to determine
the solution of such as are already formed, together
with the interstitial deposits of tissues and sometimes
even the tissues themselves.
If, then, these adhesions and condensations do occur,
which are represented by the hypothesis as the cause
of cure by these trusses, the evidence of their existence
should be found during the continuance of the primary
redness, and cannot be supposed to commence at a later
period, when the parts have become familiarized to the
pressure of the instrument.
Immediately after the application of a truss of the
first class, the subcutaneous fat beneath the block be-
gins to disappear by absorption, especially at the part
corresponding with the shoulder or most prominent
part of the block. After the disappearance of the
adeps, the block still continues to sink deeper and
deeper, until, in fleshy persons, it appears to be almost
embedded; and, on removing the instrument, the in-
teguments present a mould of the block, nearly or quite
complete. This condition is observed before the sub-
sidence of the primary redness in some cases, (Case
XII.) and in others the parts may possibly become
accustomed to the pressure before the depression of
the integuments is so strongly marked; but in fact it
has been observed in practice that active irritation of

REPORT ON HERNIA.
29
the skin is generally reproduced from time to time,
being complicated with the secondary debility of the
vessels already described; or, in other words, the skin
rarely becomes perfectly accustomed to the pressure of
blocks of this class.
The tenor of the specifications of the patents of Dr.
Hood and Mr. Stagner, (the only authorities on the
subject known to the Committee,) induces us to believe
that the authors of the hypothesis did not intend to
carry the supposed condensation of the skin, cellular
tissue, and fascia superficialis beyond the point at
which the above detailed appearances are observed;
but that measures were then designed to be taken in
order to lessen or control the amount of irritation pro-
duced by the instrument, either by the substitution of
a less severe block, or by placing next the skin some
layers of silk or other tissue to prevent the direct action
of the wood. Your Committee are therefore of opinion
that it would not be quite consistent with impartial
justice to include the ulterior effects of the continued
pressure of the blocks in the investigation of the truth
or falsity of the hypothesis. These ulterior effects will
be mentioned hereafter; but the condition of the parts
about the hernial orifice, or the abdominal canal, at
the spot where the block presses, at the time when it
is most deeply embedded, and during or after the high-
est irritation, is as follows:
The cutis vera, presenting one or the other form of
redness above described, is sometimes thickened a little
around the edges of the block, where a general puffi-

30
REPORT ON HERNIA.
ness of the integuments is occasionally observed. In
some instances this thickening of the true skin is per-
ceptible for a short distance beneath the more inclined,
or inner and upper edge of Hood's inguinal block; but
with all the instruments of this class which have been
seen in use, the parts where the pressure is consider-
able, or, in other words, those which are nearest the
hernial orifice when the instrument is rightly applied, are
marked by no thickening of the skin; and, in some
instances, that membrane is rendered obviously thinner
than when in its normal condition, even when the case
has not advanced beyond the primary stage of irritation.
The subcutaneous cellular tissue is found in every
instance reduced in thickness by the obvious removal
of the adeps, and by some process producing still
greater compression. The Committee have seen no
evidence whatever of the slightest thickening, either
in the fascia superficialis, the abdominal tendons, or
the edges of the external abdominal ring when that
part has been acted on: and in all the cases the skin,
where most closely approximated to the fascia, can be
made to glide freely over it, when moved by the finger.
After the final removal of the truss, the parts thus
flattened or impressed by the block rapidly regain the
general level of the abdomen. The cellular tissue re-
ceives anew its characteristic deposits, both within and
beneath the cutis vera, and the adeps reappears. A
few weeks are sufficient to effect this change; it is
sometimes completed before the entire subsidence of
the secondary redness, and it has been known to com-

REPORT ON HERNIA.
31
mence even under the pressure of the blocks of Dr.
CHASE's trusses.
Your Committee feel compelled to regard these facts
as conclusive against the truth of the doctrine, that the
trusses or blocks of the first class produce a real con-
densation of, or adhesion between the skin, the sub-
cutaneous cellular tissue, and the fascia superficialis
or abdominal tendons.
If the depression were the result of a true condensa-
tion, it would be utterly impossible that the skin should
retain, as it invariably does, its mobility upon the parts
beneath. If adhesions actually took place, and the
hypothesis which considers the cellular tissue as a
membrane containing cells be true, the obliteration of
those cells would render impossible the rapid repro-
duction of fat and the disappearance of the depression
which has been described. If, on the contrary, that
hypothesis be correct which represents the cellular
tissue as a homogeneous mass, then the existence of
adhesions between the cutis and the parts beneath
could not permit the skin to rise again to its natural
level until the accidental membranous connexions were
gradually elongated by mechanical or other forces;
but the parts interested in the present case are not
subject to any mechanical distending forces, in proof
of which the Committee will refer to the letter of the
Chairman already quoted; nor can it be supposed that
interstitial deposition alone could occasion the neces-
sary stretching of the adhesions within the time re-
quired; for this process is always slow and tedious,

32
REPORT ON HERNIA.
even under the action of very powerful forces, as is
seen in the adhesions following inflammations of se-
rous cavities. If any should believe it possible that
the renewed interstitial deposits might elevate the skin
to the natural level, the Committee would merely sug-
gest that these depositions could occur only in the
intervals of the factitious membranes formed by the
adhesions, and hence, that the skin thus elevated, would
be inevitably rugose-a character totally inconsistent
with the facts of the case. Moreover, we often witness
similar depressions of the integuments among the
effects of long continued pressure by bandages and
splints in surgical cases-as, for instance, over the
tibia in ulcers of the inferior extremities-yet, in no
case do we see the skin adherent to the parts beneath,
unless in places where there has been an actual loss of
substance or the establishment of the suppurative
process.
Your Committee, therefore, entertain decidedly the
opinion that the hypothesis of condensation and adhe-
sion is untenable.
It may now be asked, if adhesion and condensation
are not produced by the first class of trusses, what are
their actual effects? It is plain that the inflammation
produced by the blocks, is greatest around the margin,
where the blood-vessels are left free to perform their
functions; and, that nature, in that situation, attempts
to arrest the progress of the inflammation, or to cir-
cumscribe it in the usual way. But the condensation
produced by this attempt appears to be confined, like

REPORT ON HERNIA.
33
the inflammation itself, entirely to the skin, and if the
consequent irritation be extended to the subcutaneous
cellular tissue in any instance, its effects are there con-
fined to a slight increase of the secretions, apparently
oedematous, and certainly fluid and temporary. These
changes are confined to parts distant from the hernial
orifice, and cannot have any influence, direct or indi-
rect, in opposing the exit of the bowel.
Beneath the block, where the pressure has a direct
relation to the orifice, the changes are all the result of
simple absorption.
If the form of the blocks were well adapted to the
anatomical form of the parts, this absorption, if not
carried beyond a certain extent, would render the re-
tention of the bowel more secure, by bringing the in-
strument into closer relation with the actual seat of
the accident. The question how far the blocks of
trusses of the first class are calculated to secure re-
tention, will be discussed presently; but it is proper,
in the first place, to notice the ulterior effects of the
instruments when the pressure is continued after the
degree of absorption already described has been
effected.
910 dad
In this class of instruments the pressure acts chiefly
on the parts immediately beneath the most prominent
points and the sub-angular shoulders of the blocks.
In these situations the wood is soon brought to bear
with great force, and over a narrow or small space,
upon the abdominal tendons and fascia.
4

34
REPORT ON HERNIA.
Your Committee, in their Preliminary Report, ex-
pressed their fears that in certain cases, the continu-
ance of this pressure might endanger the integrity of
the tendons themselves. They do not feel warranted
in quoting hearsay evidence on the justice of this fear,
but the Society will observe that in one instance under
their observation this result has actually taken place.
(See Case XII.) The patient is still under treatment;
a long space running perpendicularly upward from a
much dilated external ring, following the direction of
the shoulder of the inguinal block of Hood and Stag-
ner, as it was applied in that case, is greatly weaken-
ed by absorption. The abdominal tendons are there
obviously thin toward the part pressed by the heel of
the block, and are very obscurely felt toward the middle
of the space. The upper outline of the external ring
cannot be felt, and its external side seems shaded off
gradually, and becomes indistinct at its margin. The
bowel is perfectly retained by one of Dr. CHASE's large
ventro-inguinal trusses, but the ability of the tendons
to recover their original structure can only be deter-
mined by time.
The doctrine of adhesion and condensation being
overthrown, there can remain but one mode of ex-
plaining the action of the instruments and their alleged
claims as means of radical cure in hernia, viz: Their
mechanical influence in producing perfect retention of
the bowel; for, whatever changes may occur in the
hernial orifice while the instruments are applied, even
granting that these changes ultimately render their
further application unnecessary, can only be due to the

REPORT ON HERNIA.
35
exercise of the natural functions of the part affected,
and have no farther dependence on the instruments
than such as results from their mechanical action in
permanently removing the substances which were pre-
viously present from time to time in the false passages
which constitute the disease.
We will now, therefore, proceed to examine the re-
tentive power of the trusses of the first class, so far
as the subject remained unfinished in the Preliminary
Report.
Is is seleciona mobles
The trusses with conoidal blocks may be safely dis-
missed with a very few words. If their points be
placed accurately over the hernial orifice, whether the
intestine makes its exit by the internal or external ring,
or at any other point on the surface of the abdomen,
these blocks must act as distending forces; and, when
the absorption consequent upon their pressure has
reached its maximum, they substitute the constant
presence of an unyielding solid body lined by the in-
teguments for the occasional presence of a soft and
pliable viscus in the false passage-a state of things
in which the remedy is literally "worse than the
disease!"
Eberle's or the Rachet Truss, with a wooden or
ivory block, is an instrument which has never attract-
ed very general attention from the profession. The
peculiar mode by which the block is attached to the
spring is liable to very grave objections; but as these
have been very fully discussed in the work of Dr.

36
REPORT ON HERNIA
CHASE, the Committee deem it unnecessary to dilate
upon them here.* The block itself is tolerably well
calculated for some forms of ventro-inguinal or direct
hernia, but falls, in this respect, far behind some of the
more recent improvements. For common inguinal
hernia its mechanical construction is badly calculated,
as it is very difficult to cause its longitudinal diameter
to agree at all with that of the abdominal canal; and
the enlargement of its lower extremity occasions its
pressure to be chiefly exerted on the external ring,
where it is least required. It is highly probable that
the internal ring was seldom protected at all, in the
majority of the cases in which it was employed, and
could never have been very securely guarded in any in-
stance. Yet, notwithstanding these disadvantages, it
is said to have affected some radical cures of hernia,
as indeed most trusses do occasionally. Your Com-
mittee have never seen it in actual use, but though it
is obviously less dangerous to the integrity of the ten-
dons than either of the other trusses of the first class,
they cannot recommend any further trials of its value,
as more recent contrivances are obviously safer, and
more certain in their action.
Neither this truss, nor those with conoidal blocks,
are applicable to femoral hernia; nor could the former
be employed in umbilical hernia.
* Chase on Hernia, p. 48. Tengg
Borocite
E

REPORT ON HERNIA.
37
STAGNER'S BLOCK, WITH ITS ATTACHMENT,
AS TAKEN FROM A DRAWING MADE IN THE PATENT OFFICE AT WASHINGTON,
16
00
B
5
FIG. 5.-A The Block. B The Block-rider.
300
dovodi
beweir
In taking up the consideration of the apparatus of
Stagner and Hood, it should be premised, first, that
Mr. Stagner's specification contains no claim to origi-
nality, except in regard to the form of the block, and
perhaps the hook, which replaces the button commonly
used for fastening the strap of the truss; the instru-
ment being precisely similar in all other respects to
the common old inguinal truss: and, secondly, that Dr.
Hood's specification contains no claim to any truss with
a spring, so far as your Committee are capable of com-
prehending the language of the document, which is not
entirely divested of apparent ambiguity. His claims
cover certain blocks invented by him, but he does not
appear to claim the inguinal block, which the Com-
mittee, in their Preliminary Report, regarded as essen-
tially the same with that of Stagner.* He claims also
* Your Committee have examined this block with great atten-
tion; they can discover no peculiarity in its structure, other than
the simple fact that it is rendered smooth. It is the block of Stag-
ner.-Prel. Rep.

38
REPORT ON HERNIA.
a variety of compound and complex drawers, belts, &c.
by means of which the blocks were to be applied with-
out the aid of any main truss spring.* But it was
thought unnecessary at the time of the Preliminary
Report, to go into the investigation of the action of
these contrivances; and, as they have been exhibited
to the Society on a former occasion, the Committee
will confine their remarks, at present, to the simple
notification of their belief that these belts and drawers,
viewed as means of retention in hernia, are vastly
inferior to the simplest springs of the old trusses,
whatever may be the form of the pads or blocks em-
ployed. This opinion is given on broad mechanical
principles, for the Committee have not deemed it
necessary to subject it to any practical test.
The adaptation of the blocks of Dr. Hood to the
springs of common trusses, is mentioned incidentally
in his specification. It is directed that when the cir-
cumstances of the case permit, this adaptation should
be made; and, as the Committee believe that all cases
which admit of the application of the blocks, admit also
* In the specification of Dr. Hood, much is said of certain ap-
paratus of a very complex character, in the form of numerous belts,
drawers, spring-belts, compresses, springs, &c., with explanations
of their modus operandi, and claims to originality with regard to
special portions of these contrivances.
Specimens of these apparatus lie upon the table, but your Com-
mittee do not feel warranted in detaining the Society, by offering
any remarks upon them here, because after waving all the nume-
rous mechanical and physiological objections to their use, their com-
plexity alone still rests as a most formidable barrier against their
claims.-Prel. Rep.

REPORT ON HERNIA.
39
of the application of the spring, their analysis will be
confined to the action of the blocks as connected with
springs, similar to those of ordinary trusses.
3o his
The umbilical blocks of Hood do not appear to differ
essentially from those previously and occasionally em-
ployed by surgical practitioners, unless it be in the
mode of attachment by means of a spiral spring; and
the Committee have nothing to add to the remarks on
these instruments made in the Preliminary Report.
(Op. cit. p. 312.)* They have little additional remark
to offer upon the femoral block of the same inventor,
except to point out the fact, that as the prominent line
of the block must necessarily cross the cord of Pou-
part's ligament before its elevated point can reach even
the spot at which the bowel, in this form of hernia,
protrudes in front of the level of the fascia lata, it is
impossible that the instrument can be brought into
close relation with the hernial orifice beneath Gimber-
nat's ligament, except by the rupture or absorption of
the ligament, or by a degree of compression intolerable
to the patient; and that if the necessary relation could
*"For umbilical hernia, Dr. Hood has also patented two forms
of blocks. These are designed for application, by means of a pe-
culiar belt, also claimed as original; in the centre of which is a
metallic plate, connected by means of a spiral spring with another
similar plate, upon which the block is secured. The spring is not
claimed by the patentee, and in the blocks your Committee discover
nothing unusual."-Prel. Rep.
The belt here claimed by Dr. Hood is the common Russian ab-
dominal band, usually seen on sale in all the clothing stores.
H. C.

40
REPORT ON HERNIA.
be established, the long plane presented by the block,
so slightly inclined as it is to the rout of the intestine,
could not exert any perfect retentive power without the
aid of intolerable compressive force. It is but just to
state that the instrument under notice shares this ob-
jection in some degree with all its predecessors in the
treatment of femoral hernia; for they all press upon
Poupart's ligament. None of them address themselves
directly to the femoral ring. The objection, indeed,
weighs more heavily against the block of Dr. Hood
than against the soft pads of the old trusses; for the
latter, by yielding to the pressure of the ligament, and
expanding below it, do offer some valuable portion of
upward pressure by acting on the soft parts beneath
its margin; whereas the solid block, being altogether
unyielding, exerts scarce a particle of such influence.
Your Committee deem no further reasoning necessary
to account for their disapproval of this instrument.*
* "The Society is presented also with the pad invented by Dr.
Hood, for the treatment of femoral hernia, both with and without
the spring of the truss. (See fig. 5, Prel. Rep.)
"We forbear to detain the Society with a complete analysis of
its intended mechanical operation, referring the curious to the cer-
tified specification of Dr. Hood's patent, obtained from the Patent
Office at Washington, which lies upon the table. Its chief design,
however, was to produce a closure of the femoral ring, an effect
which, in the opinion of your Committee, cannot result from such
an instrument, owing to the peculiar relation existing between the
edges of Poupart's and Gimbernat's ligaments. Your Committee
feel compelled to disapprove of this pad, as uncertain in retentive
power, and necessarily extremely annoying to the patient.
"This ground is taken on plain mechanical principles, and does
not appear to require the test of experiment. But if evidence of

REPORT ON HERNIA.
41
The inguinal block claimed by Stagner, and adopted,
and perhaps somewhat modified, by Dr. Hood, has
been made the subject of comment in the Preliminary
Report-where its advantages, and the valid objections
against it, have been stated. Many cases who had
employed this instrument have presented themselves
to the Committee, and in a few only of these has the
retention of the bowel been constant. They can recall
but one instance in which the evidence of the friends,
or that of the patient, tended to show that the bowel
had never descended during the employment of the
truss, after it had been sufficiently adjusted. (Case III.)
That occasional radical cures have been effected by
the use of trusses armed with these blocks, is probable,
for such results have sometimes followed the use of
almost every truss; but, waving the pain and incon-
venience produced by the block, which are often very
considerable, the Committee have seen sufficient evi-
dence that it furnishes but insecure means of retention,
in any form of hernia, and that in the common inguinal
form, for which it is expressly recommended, it cannot
be made to press sufficiently on the internal ring, while
the lower point of the shoulder acts upon the external
ring. From the details of Case XII., to which refer-
ence has been already made, the Society will judge
how far the linear pressure of the elevated ridge of the
block, and the small dimensions of the most prominent
this character be demanded, it can be given by one of the most
ingenious members of the Society, who has actually and faithfully
employed it."-Prel. Rep.
5

42
REPORT ON HERNIA.
part, may endanger the integrity of the tendons and
effect the enlargement of the external ring. The ob-
jections to the form of this block, appear to outweigh
any advantages resulting from its solidity.*
* "In examining carefully the mechanical principles involved in
the common inguinal blocks of Stagner and Hood, these instruments
appear to possess one important advantage over the more common
forms of the soft pads of the trusses in general use, and they are
likewise liable to two equally important objections. The advantage
is found in the gradual arch of the abdominal face of the block,
which causes it to adapt itself more regularly than the ellipsoidal
pads to the peculiar form of that part of the abdominal parietes in
which the inguinal canal is placed, and in the abruptness of the
pelvic face, which enables the instrument to approach more nearly
to the pubis, without overlapping that bone, and occasioning serious
inconvenience to the patient, while, at the same time, efficient
pressure is effected at the lower end of the block.
"The great objections are these:-1st. The tendency to an elon-
gated semi-fusiform shape, renders the block so extremely promi-
nent at the lower extremity of its shoulder or most prominent line,
that the remainder of that line produces no very efficient pressure
upon the rout of the inguinal canal, the principal effect of the instru-
ment being confined to the neighbourhood of the external ring, and
the more important point-the internal ring-being left insecurely
supported. 2nd. The great elevation of the lower end of most of
the blocks, seen by your Committee, is calculated, in part, to coun-
teract the advantage of the gentle curvature of the abdominal face,
by causing the shoulder of the block to act in a linear manner, the
strong compression being confined to a very narrow space, as has
been proved by cases under the observation of the Committee.
This error increases the uncertainty of retention, and it is unne-
cessary to the production of irritations amply sufficient to fulfil the
hypothetical indications pointed out by the inventors-a fact of
which your Committee have had, in their opinion, sufficient prac-
tical evidence. Moreover, the same peculiarity of form causes the
lower or internal extremity of the shoulder to act upon the external
ring, somewhat in the manner of a very small pad, and hence, in

REPORT ON HERNIA.
43
The ventro-inguinal block of Hood, was condemned
with less hesitation in the Preliminary Report-but it
is now proper to add the reasons for this condemna-
tion. The block was intended, according to the speci-
fication of the inventor, to draw together the parts
about the ring of a ventro-inguinal hernia, and to pro-
duce adhesion between those parts and the edges of
the ring all around the orifice. It is unnecessary to
repeat the reasoning which appears to us to prove the
fallacy of this theory of adhesion, but the impossibility
of effecting the adhesion is the lightest objection to the
instrument. A stronger one is found in the fact that
the concavity of the block necessarily permits the bow-
els to protrude for a certain distance, so as to occupy
the hernial orifice and prevent its contraction, should
nature attempt to close it by that process.
The only block of the first class now remaining un-
noticed, is the ventro-inguinal block, with a parabolic
projection, termed by Dr. Hood "the scrotal block,"
which was approved, with justice, in Preliminary Re-
port, (Op. cit. 323,) as it secured a more effective
retention of certain cases of ventro-inguinal hernia
than the armature of any truss then known; but the
Committee considered "a more perfect instrument to
fulfil the same purposes, both possible and desirable."
ventro-inguinal hernia, there would be strong danger of a conse-
quent dilatation of the ring, and an exacerbation of the disease.-
Prel. Rep.
PANETAR

44
REPORT ON HERNIA.
OTG
FIG. 6.-HOOD'S VENTRO-INGUINAL BLOCK.
25359
he
17
FIG. 7.-Transverse section.
FIG. 8.-Longitudinal section.
8
SEO
6
ES
Su
FOLK
JUOLS
The defects perceptible in this truss-block, appear
to have been, in great degree, the result of the peculiar
opinions of the inventor as to the modus operandi of
his apparatus-the principal error consisting in the
undue elevation of the inferior margin of the block,
which was evidently designed to produce the degree
of irritation held necessary to effect a cure. Another
highly important defect was the strong curvature of
the lower margin, which appears as though it were
modelled upon the supposition that the external orifice
of the abdomen is, as its name implies, a ring-and
not, as nature made it, nearly a triangle, with the two
columns of the external oblique forming its lateral
boundaries and the upper edge of the os pubis its base.
The transverse fibres which truncate the superior acute
angle of this triangle, do indeed present an arch up-
ward in the normal condition of the parts, and the os
pubis is somewhat curved downward between the

REPORT ON HERNIA.
45
columns, so that the orifice bears some resemblance
to a ring when felt by the finger after reverting the
skin of the scrotum; but in ventro-inguinal hernia, these
transverse fibres are generally broken or absorbed, and
the pubic base being much elongated by the separation
of the columns, presents but a very slight degree of
curvature. The block under review is but ill adapted
to the form of this part of the pubis, and hence it does
not effect retention with sufficient certainty and con-
stancy to give entire satisfaction.rog
10
22
The observations of the Committee upon these de-
fects have given rise to the contrivance of a most beau-
tiful instrument, the merits of which will be noticed in
the sequel.
The specification of Dr. Hood's patent also contains
some claims to a certain mode of succession in the
application of different blocks in the same case, at differ-
ent stages of the treatment, and also, to the interposition
of some layers of silk between the blocks and the in-
teguments, and the removal of these layers from time
to time, seriatim;* -as these measures relate only to
the regulation of the degree of irritation produced by
the apparatus, and as we have been compelled to op-
William Hall Timbrel, Esquire, of London, has published a
work entitled "Practical Observations on the management of Rup-
tures," which was republished in Boston in 1809. Mr. Timbrel
here describes what he calls his new method of employing cushions
of calico, or folds, placed under the pads of trusses, layers of which
were to be removed from time to time, as the cases might require.
H. C.

46
REPORT ON HERNIA.
pose the doctrine which regards this irritation as de-
sirable, we do not think it right to occupy the time of
the Society with any comments upon the subject of
these claims.
sus cerda
From the result of all the evidence presented to
them, and their reasonings upon it, the Committee are
irresistibly drawn to the following conclusions. 1st.
That the trusses of the first class do not secure the
complete and permanent retention of the bowel with
all the certainty which may be obtained by mechani-
cal means. 2nd. That although it is extremely pro-
bable that radical cures may be occasionally effected
by the use of such instruments, it has not been proved
that the success following their employment exceeds
that which has been obtained by the better kinds of
trusses previously in use. 3d. That the action of these
instruments is often attended with serious and unneces-
sary inconvenience, uneasiness and pain. Lastly, That
their employment for too long a time, when the degree
of pressure exerted by them is considerable, sometimes
produces absorption of the tendons, dilatation of the
hernial orifice, and an extension of the evils they are
designed to remove; and that any attempt to obviate
this danger, by lessening the pressure while the sup-
port of the instruments continues to be required, will
diminish the security of the retention. For all which
reasons the Committee do not feel warranted in making
a favourable report on the claims of this class of
trusses upon the confidence of the Society.
In entering upon the analysis of the merits of the

REPORT ON HERNIA.
47
second class of trusses, the labour becomes more com-
plex in character, and requires that the subject should
be divided under more numerous captions.
As the course of the previous argument required
that Eberle's or the Rachet Truss should be noticed
in the former part of this Report, rather than in its
natural order among its fellows of the second class,
there remain for examination only the six instruments
of Dr. CHASE.
The object of these instruments is to secure the
perfect and permanent retention of the viscera in her-
nia, in order to permit the powers of nature to effect
a radical cure after the removal of the misplaced parts
which are supposed to offer the greatest obstacle to
her success. It is proper, therefore, to investigate, in
the first instance, how far they fulfil the all important
purpose of retention; leaving their effects upon the tis-
sues, the modus operandi of nature, in effecting the
cure, and the extent of the results to be discussed in
the sequel under distinct heads.*
* In the month of July last, 1834, Mr. Heber Chase expressed
to the Chairman of the Committee a desire that the merits of cer-
tain improvements upon the blocks already noticed, claimed by him
as original, should undergo a full investigation before the Commit-
tee, both as regards their mechanical principles and their practical
effects. Throwing himself upon the profession, and before the
world, the Committee feel bound to bear honourable testimony to
the disinterested frankness with which this gentleman has facilitated
their investigations, even when these have conflicted with his in-
terests. Claiming no exclusive privileges, and concealing no fail-
ures, he has presented to the Committee all the evidence which

48
REPORT ON HERNIA.
ANATOMICAL VIEW OF THE ANATOMY OF HERNIA.
abreg
10
9
a
Ter
FIG. 9.-The skin and superficial fascia removed from the left side of the
abdomen, and the left groin, so as to display the surface of the tendons, the
position of the abdominal rings, and canal, &c.
a The internal abdominal ring, marked in dots, as seen through the
tendon of the external oblique muscle.
their rather tardy action on his suggestions have enabled him to
produce; and they have now the satisfaction to announce, that,
commencing their researches with doubt, and with rather unfavour-
able preconceptions, their opinion has been rendered highly favour-
able to the claims of several of his improvements, by the weight of
the few observations which they have been enabled to make. Your
Committee will not permit, however, any feeling of personal grati-
fication to interfere with the rigorous analysis and honest report of
surgical facts. The members are not disposed to suffer the influ-
ence of men to interfere with their calm judgment of medical
opinions.-Prel. Rep.

REPORT ON HERNIA.
49
b The external ring, formed by a natural separation of the fibres of the
same tendon; the spermatic cord seen passing through it to the scro-
tum, and the dotted line between the two rings marking its course
upwards, under the tendon, through the abdominal canal.
c The spot where the tumour in femoral hernia is generally seen when it
rises from beneath the fascia lata of the thigh, the femoral canal not
being visible in this view, because it is hidden by Poupart's ligament.
d The umbilicus.
e The middle of Poupart's ligament.
f The anterior superior spinous process of the os ilium.
g The body of the os pubis, forming the lower boundary of the exter-
nal ring.
h The saphena vein passing through the fascia to join the great femo-
ral vein.
The inventions and improvements of Dr. CHASE,
many of which have been adopted since the presenta-
tion of the Preliminary Report, extend to all parts of
the truss and its appendages, and his attention to
minute but highly important details has been carried
to an extent never equalled by any of his predecessors
in this branch of surgery. The complete instruments
employed by him are-1st. The Inguinal or Common
Inguinal Truss. 2nd. The Ventro-Inguinal Truss.
3d. The Femoral Truss. 4th. The Umbilical Truss.
5th. The Umbilical Belt. 6th. The Double Truss.
Each of these demands separate notice, and in most
of them the following parts require distinct examina-
tion. (a) The Block; (b) the Block attachment; (c) the
Spring and Strap-attachment; (d) the Appendages.
cow 22n
edi essold elesine to own vinster edr of bring916
6
bold foning

50
REPORT ON HERNIA.
DAISE
CHASE'S COMMON INGUINAL BLOCK, WITH
ATTACHMENT.
eds bus mut
absongs
fer tone of s
issons ɑ voit regis
wory still ni ofitery gufed
au of 5
4. To sibhiar edT
heins efT
Fotes ads
eemes ati publu eenk
Tenso lank rob is adt de
si nedy neee license si siated isos
Jon fanse tetor 10
Bu
d
b
daron's
12
(h
11
d The block-slide.d
e The window in the block-slide.
ir len
ose ofT
ALLOT ST
all to stromo
20
oilt conia barges goed 0751
FIG. 10.-a The extremity of the main-spring of the truss. ooit
b The block.
c The brass block-rider: the screws by which it is attached being
covered by the block-slide.
dgid Jud sinni
6003 2018n inotro no of
ff The two broad-headed screws of the block-adjustment, securing the
rider to the slide, and, when loosened, sliding freely in the window.
g
The soft iron flexible neck, attaching the block-slide to the main-
spring.
h The button for the pelvic strap, which is generally used for the peri-
neal strap also..do
The proper perineal strap-button on the end of the block-side is omitted
in this and some succeeding figures, to prevent confusion.
FIG. 11.-Longitudinal section of the block.
FIG. 12.—Transverse section of the same.gloold out (6) nod
nora A eik Anemostre as bus gang?
(a) Of the Block.*-The block of this truss was
* "In regard to the retentive power of particular blocks, the
Committee are prepared to express their warm approval of the in-
guinal block of Mr. Chase, in which, at present, it can suggest no
improvement."-Prel. Rep.

REPORT ON HERNIA.
51
warmly approved in the Preliminary Report, (Op. cit.
p. 323.) and it has amply maintained its character
throughout the more recent investigations: it is so
perfectly adapted to the form of the parts interested
in common inguinal hernia, that the Committee are
unable to perceive in what manner it could be im-
proved; nor has it ever failed, under their observation,
in retaining the bowel both permanently and completely
during the time of its employment, after the first few
days required for the accurate adjustment of the in-
strument. Nothing farther appears necessary to prove
the decided superiority of this block over all others
known to the profession, in the particular form of her-
nia for which it is designed.
(b) Of the Block-attachment.-Two very important
improvements upon the old modes of attaching the pad
to the spring of the truss are observable in the block-
attachment of the Inguinal Truss. The block is sur-
mounted by a thin oval plate of brass, termed by the
inventor a block-rider; and this is adapted to the under
surface of an iron plate of nearly similar form, called
the block-slide, to which it is attached by means of
two round-headed screws, playing freely, when loosen-
ed a little, in a longitudinal fenestrum in the block-
slide, so as to admit of any required change of the
position of the block in this direction, to the extent of
about an inch in the trusses designed for adults. The
block-slide is connected to the spring by means of a
round neck of soft iron, about three-quarters of an
inch in length, sufficiently stiff to resist any change of
shape during the most active movements of the patient,

52
REPORT ON HERNIA.
and sufficiently pliable to act like a universal joint
under the hands of the surgeon. The combined action
of the slide and the neck enables us to adjust the block
with the utmost precision to the edge of Poupart's
ligament, the rout of the abdominal canal, and the in-
ternal ring, whatever may be the peculiar form of the
abdomen of the patient, while the block remains in-
variably in the exact position chosen by the surgeon;
advantages possessed by none of the trusses previously
in use, so far as they are known to the Committee.
These improvements are, in themselves, sufficient to
add very greatly to the value of the instrument.
(c) Of the Spring and Strap-attachment.-The endless
varieties of form which have been given to the springs
of trusses, render it apparently impossible that any
thing intrinsically novel, in this part of the hernial
apparatus, should be presented to the public hereafter;
but it is of the utmost importance that the profession
should determine what class of springs are calculated
to give the greatest degree of security and permanency
to the action of trusses.to
estions
He
Dodacite zi
Sodoen
bold
This subject has been amply discussed in the work
of Dr. CHASE already repeatedly cited; and the Com-
mittee are prepared, after due reflection, to coincide
in the opinion expressed by that gentleman, that the
semicircular steel springs of Salmon and Ody* are
objectionable, because they are brought into accurate
* For a drawing and description of "Salmon and Ody's patent
ball-and-socket attachment," see CHASE on Hernia, Fig. 5, p. 46.

REPORT ON HERNIA.
53
relation with the body only at the spots corresponding
with the spine and the hernial orifice; the whole arch
of the spring resting loosely over the side of the pelvis
without a fixed location, and remaining liable to con-
tinual change of place from the movements of the
glutei muscles and the reaction of the dress of the
patient. The changes just mentioned must inevitably
lead to the danger of corresponding changes in the
position of the pads or blocks, and consequent inse-
curity of retention. The motives for the invention of
this class of springs were the three following, and they
are obviously fallacious. 1st. It was supposed that
the pressure of the spiral elastic springs, being exerted
throughout their whole length, renders them liable to
derangement by the motions of the parts on which they
press; but, excepting on the front of the hypogastric
region of the abdomen, those parts have so slight a
degree of mobility-based as they are upon the solid
structure of the pelvis, and almost uninfluenced by
muscular contractions-that their alterations of figure
are of no real importance. The changes in the figure
of the hypogastric region are fully compensated by the
elasticity of the spiral springs, and those of the parts
over the ring of the ilium are successfully counteracted
by perineal straps, so that the accuracy and perma-
nence of retention are not contravened when spiral
springs are employed. 2nd. It was supposed that the
changes of shape in the hypogastric region required
some mode of adjustment more complete than that
effected by the elasticity of the main spring, to enable
the pad or block to accommodate itself at all times to
the form of the parts; and hence the ball-and-socket

54
REPORT ON HERNIA:
pad attachment, to which the semicircular spring was
deemed peculiarly adapted. But, if desirable, this
mode of attachment may be as readily employed in
connexion with the spiral spring. Your Committee do
not deem it desirable; because the ball-and-socket
attachment renders secure but one point on the back
of the pad or block, while the circumference may be
tilted in any direction by the pressure of an intestine
from within, almost as readily as by the movements
of the abdomen, to which the pad is designed to yield;
for the soft and compressible surface of the hypogastric
region cannot securely prevent this tilting when the
adjustment of the pad is not remarkably accurate, or
when the propulsive force of the intestine in hernia is
considerable. A third argument urged in favour of the
introduction of semicircular springs was drawn from
the tendency of the strap attached to the spiral spring
trusses to draw upwards, and thus displace the pad;
but this difficulty is completely removable by giving to
the spiral spring and the accessory parts of the truss
a proper form and disposition, as will be explained
hereafter.
lul ora
abog sil
opods
helesine odt to visitasle
Your Committee are therefore of opinion that Dr.
CHASE has done wisely in adopting the spiral spring,
and retaining the strap so as to encircle the whole
pelvis by the truss, in preference to the semicircular
spring and universal joint of Salmon and Ody's instru-
ment, and the modifications of the same by the late
Dr. Hull, of New York, the Rev. Mr. Reed, of Geor-
gia, đc. &c.*
Hold re bes
* Many other modifications of the truss of Salmon and Ody

REPORT ON HERNIA.
55
Although there is nothing positively novel in this
part of the Inguinal Truss of CHASE,† the inventor has
were presented before the Committee, but are not specified in the
Report, probably on account of their number, and the sameness of
principle in their action. Among these may be enumerated the
trusses of Farr, Marsh of New York, Glover of New York, Sher-
man of Baltimore, &c.
H. C.
#12
† On the 25th day of August, 1837, I addressed to Dr. REYNELL
COATES, the late Chairman of the Committee, the following note:
MY DEAR SIR,
Will you allow me to ask your opinion of the improved truss-
spring with a dorsal slide, which I had the pleasure to submit to
your examination a few weeks ago? I wish to publish this opinion
in connexion with the Report of the Committee on Hernia, of which
you were Chairman. Should your urgent engagements as a mem-
ber of the Scientific Corps of the United States' Exploring Expedi-
tion permit you to give one moment's attention to the subject before
your departure, I shall consider myself under deep obligations to
you for a candid expression of the value you attach to the improve-
ment.
With great respect,
REYNELL COATES, M. D.,
Your obedient servant,
HEBER CHASE.
soubojni.od
COMPARATIVE ANATOMIST TO THE U. S. SURVEYING
AND EXPLORING EXPEDITION.
Philadelphia, August 25th, 1837.
CE
Have o
To this note the following answer was returned:
MY DEAR SIR,
Your note of the 25th inst. is in hand. It is altogether impos-
sible for me to enter into any experimental examination of the
value of your "improvement," at present; but the few moments
which I have been able to give to the consideration of the purely

56
REPORT ON HERNIA.
established definite rules for the degree of temper and
the extent of the various curvatures of the spring, and
also for the position of the strap-button, which render
it easy to adjust the instrument more securely and per-
manently in all cases than can be done when these
points are left to the discretion of instrument-makers.
Experience has decided that there is an advantage in
giving an elastic temper to all that portion of the spring
which intervenes between the pad-attachment in front
and the opposite sacro-iliac symphysis in the rear, but
that the portion extending from the latter point to the
opposite side of the pelvis should be so far softened as to
admit of adjustment by being permanently bent. Three
inches of the hinder extremity are left ductile in all the
trusses of the full size; and thus the necessity of making
an instrument expressly for each individual case (the
great difficulty in the employment of spiral springs
mechanical properties of the truss-spring with a dorsal slide, have
induced a belief that some increased steadiness, accuracy of action
and adaptation may probably result from its introduction as a part of
your hernial apparatus. At the same time, I feel reluctant lightly to
admit the propriety of modifying a series of instruments already
so perfect in their action; and if the proposed change, or any other,
be introduced, it should be after more mature reflection, and more
extended practical testing than my present and future duties will
allow me to make or to witness. Under these circumstances it
gives me great pleasure to believe that no man in the profession is
so well qualified as yourself to observe and decide upon its merits
after it has stood the test of experience.
東​選
​I have the honour to be,
With great respect,
coqmi tertiogall
image large
elnemour yol added the
To HEBER CHASE, M. D. dr of orig
Your obedient servant,
REYNELL COATES.
olds read evad I noidy

REPORT ON HERNIA:
57
entirely of tempered steel) is completely obviated, with-
out sacrificing the accuracy of the adjustment on the
one hand, or its permanency on the other.
donmal
od
It has been customary to curve downward the an-
terior end of the spiral spring, so that when the part
which lies across the back is horizontal, the front ex-
tremity may approach more nearly toward the abdo-
minal canal. In CHASE's Inguinal Truss this curvature
does not exceed three-fourths of an inch, and its com-
mencement is found far back upon the costa ilii when
the instrument is applied; so that the spring, in passing
forward from that point, winds downward below the
anterior superior spinous process without encroaching
too much upon the bellies of the glutei muscles or dis-
turbing the proper position of the spring and strap on
the back part of the pelvis. Any further increase of
this curvature is attended with inconvenience, by giv-
ing the direction of the strap too much obliquity, and
disposing the instrument to tilt upward in front; and
such increase is rendered altogether unnecessary by
the soft iron neck of the pad-attachment. In the last
three inches of the anterior end of the spring there is
another curvature, resulting from a slight tortion of the
axis of the generating curve of the spring, which brings
the flat side of this part of the spring into more com-
plete correspondence with the surface of the hypogas-
tric region—a matter of much importance to the com-
fort of the patient, and one giving additional security
to the position of the instrument.
It has been customary, almost invariably, with truss-
7

58
REPORT ON HERNIA.
makers to place the strap-button upon the plate or
expansion which supports the pad, but Dr. CHASE has
very wisely affixed it to the anterior end of the spring;
by which means the obliquity of the strap is much
diminished, and the pelvis is enclosed by the instrument
in a direction approaching very nearly to the circle,
the strap lying altogether above the level of the block-
slide, and the disposition of the instrument to tilt or
ride upwards being reduced almost to nothing.m
sob
The Committee consider the establishment of a fixed
model for the triple curvature of the spiral spring, and
the position of the strap-button, as a highly important
recommendation to the instrument under notice.
(d) Of the Appendages.-The perineal strap is never
wanting in the Inguinal Truss of Dr. CHASE. It is
attached behind by means of a sliding loop, through
which pass the spring and cover. Before, it is com-
monly secured to the strap-button, but each instrument
is also provided with another button made expressly
for the perineal strap. This is seated on the lower
extremity of the block-slide, and may be used to give
additional security and force to the action of the block
when the lower part of the abdomen is very prominent
and loaded with fat. The back-pad is a very import-
ant appendage to the truss, giving great certainty to
the position of the instrument, by protecting from irri-
tation the spinous processes of the sacrum, and filling
the interval between the spring and the integuments
along the median line on the back of the pelvis. Some
very important improvements have been made in the

REPORT ON HERNIA.
59
construction and mode of attachment of this pad. It is
formed of a simple circular disk of tin, about four
inches in diameter, covered with soft buckskin, and
lightly wadded. A broad sliding loop of leather sus-
pends it on the spring and cover, so that its position
may be adapted exactly to the size of the patient and
other accidental circumstances. This perfectly free
mobility of the back-pad is believed to be a novel ar-
rangement and one of high practical importance; for
it is found that the parts about the back of the pelvis
are so intolerant of even slight pressure, when very
long continued, that the subcutaneous fat becomes ab-
sorbed and the skin irritated by the mildest back-pad,
if it be worn in one invariable position for many months
consecutively. This difficulty is entirely obviated by
an occasional change of position produced by sliding
the pad a little toward one or the other side;—a change
that is not attended with any loss in the security of re-
tention, and which is accomplished more readily by the
arrangement just described than by any other known
to the Committee.
barrod lest sailingo) out 20
Dad su to zer
ail To cart Place
Aromundani afde tedi noitolysco vodi stata ei vienod
ef
Tosses oft af ment of fronteralto le corange
ent nommés d
for all to someren og bre
viert lie vd beatstone vin mondinos & vimeid losing
off 2000 to notes ont lo sacitozzedo Lesiony
adreitag tedi hormon so of die y el tromprises
La comitenice bus landlingu datupallor ellaronog
vd llon beongonery noder more ch of es bas
BOOSTUE ads

60
REPORT ON HERNIA.
CHASE'S COMMON INGUINAL TRUSS FOR THE RIGHT SIDE.
To
13
smot duode
bas id
1
bas tren
- lovor s
erden et
4727
d
a
be
Botetici
orant
Ew ylideil
bang
loqu
as fremrogist
ters bawol aidi
tadions
citano nao!
ds
beg load stoff
erthon
美​寳
​FIG. 13.-a The block and block-attachment.
devi
b The part of the spring which bears the greatest stress and requires
the highest temper.
The termination of the spring, made more flexible, and extending to
the edge of the os ilium between the two spinous processes on the
opposite side of the body.
d The back-pad seen in situ.
e The perineal strap with its end thrown round the extremity of the
spring-cover.
Having thus analyzed the several parts of the In-
guinal Truss of Dr. CHASE, the Committee feel bound
honestly to state their conviction that this instrument
surpasses all others known to them in the accuracy
and permanence of its retentive power in common In-
guinal Hernia; a conviction fully sustained by all their
practical observations of the action of trusses. The
instrument is worn with so much comfort, that patients
generally relinquish it unwillingly, and sometimes ab-
solutely refused so to do even when pronounced well by
the surgeon.

REPORT ON HERNIA.
61
CHASE'S COMMON INGUINAL TRUSS APPLIED.
ott.25.901
eirrad
D
depen
ID
O
Samp
401
de jonoap
CH
-nos doider Loussel
evon ed edt ombo
14
COTT
15
00
danisge
ottel odi
Hoold Siloa Jaod
of oldail
boboot's
voi todt ho
Sat laid
23% god don9)
The Committee find themselves unable to suggest
any improvement, or to point out any defect of princi-
ple or construction in this truss as now employed by
the inventor.
mor od
ods
CHASE'S VENTRO-INGUINAL BLOCK.
B000
onu
beybloses of
2nd 17
DRO
lien
sirged
bou
noit
Dostla
cade
noma ods
:) troner odi asin
estamos planoste algo Lev
16

62
REPORT ON HERNIA.
FIG. 15.-The attachment being in all respects similar to that in fig. 10,
no references are required.
FIG. 16.-Longitudinal section of the block.
FIG. 17.-Transverse section.
It will be recollected that at the time of the Prelimi-
nary Report, Dr. CHASE employed in ventro-inguinal
hernia, either his own common inguinal block, or a
modification of Hood's block with a parabolic projec-
tion. The former did not furnish sufficient security
against protrusion, and we have already mentioned that
the latter, though approved by the Committee as the
best solid block then in use for inguinal hernia, is
liable to some decided objections, not altogether un-
attended with danger. The Committee, therefore, stat-
ed that they considered "a more perfect instrument to
fulfil the same purposes, both possible and desirable."
(Prel. Rep. 323.) Their views on this subject having
been freely communicated to Dr. CHASE, who was
already conscious of the necessity of improvement in
this instrument, he devoted his mechanical talent to
the removal of the difficulty. The result was the con-
struction of the ventro-inguinal block, described by the
Chairman under the head of American Intelligence, in
the same number of the American Journal which con-
tains the report, (p. 543.*) At the time that the note
* "Chase's ventro-inguinal block, resembles the common ingui-
nal block, strongly compressed upon its broader convexity, until
the more sudden curvature is made to overhang the base to a great
extent, particularly in the middle of the length of the block, so
that when the block is placed on its base and viewed perpendicu-
larly, it presents on one margin a semi-elliptical curvature, and on
the other an effuse parabola. This form permits the effective pres-

REPORT ON HERNIA.
63
was written, the Committee had not enjoyed an oppor-
tunity of testing the practical application of this block.
They have since witnessed its operation in many cases,
some of which were of a very unfavourable character.
It is extremely difficult perfectly to retain a ventro-
inguinal or direct hernia by any of the forms of soft
pads, as it is indispensably necessary that those pads
should press extensively upon the brim of the pelvis,
in order that they may completely guard an orifice
bounded on one side by the pubic bone. This pres-
sure not only increases the number and severity of the
cases of varicocele, a disease of frequent occurrence,
under the use of all trusses, though seldom of much
moment, but it also gives rise occasionally to trouble-
some hydrocele, and sometimes to wasting of the tes-
ticle. The form of CHASE'S Ventro-inguinal block is
so accurately adapted to that of the os pubis, that it
has secured the bowel perfectly in every instance of
ventro-inguinal hernia in which it has been seen ap-
plied by the Committee. The primary adjustment of
the truss is considerably more difficult, and requires
more time and skill in the worst cases of this accident
than in the inguinal variety, but the ultimate success
of retention does not appear to be less perfect when
once accomplished. The pressure of this block upon
the os pubis has been made a subject of complaint in
orang
sure of the block to act very near the brim of the pelvis, without
injuring the spermatic cord, or contusing the integuments against
the bone; and it would appear difficult to contrive a form of pad
better fitted to secure the retention of the bowel in this very
troublesome variety of hernia."

64
REPORT ON HERNIA.
only one instance, and the inconvenience then resulted
from a slight mal-adjustment in the first application,
which being corrected, the difficulty never recurred.
otocusto Ismoze
doidy lo omoa
FIG. 18.-A VIEW OF THE PELVIS, WITH CHASE'S VEN-
TRO-INGUINAL BLOCK IN SITU-TO SHOW THE ADAP-
TATION OF ITS CURVATURE TO THE FORM OF THE
BODY AND SPINE OF THE OS PUBIS.
colliro a
or to W
drest of
+351
Pas
Y
11
18
blood
elt rebro ni
bogod
saemem
odbrud oproe
a a The bodies of the pubic bones.
bb The anterior superior spinous processes of the ilia.
c The ventro-inguinal block in situ.
d The symphysis pubis.
e The base of the sacrum.
f The spines of the pubic bones.
Sinoce
As regards the accidents consequent to the use of
this instrument, the coexistence of varicocele has been
observed in several instances, but the Committee think,
not more frequently than after the use of the old com-
mon Inguinal Trusses. This affection, to the extent
noticed, is so common in persons labouring under hernia,
and even among those who are not affected with any
other disease, that they feel considerable doubt whether

REPORT ON HERNIA.
65
in the cases observed, it was generally referable to the
action of the truss, to the pressure of the intestines
when protruded, or to some pre-existing cause. They
have not been able, in more than one instance, to de-
termine, positively, that it was caused by the instru-
ment, and in no case has it produced material incon-
venience. One case of slight and temporary hydrocele
has been observed by the Chairman, and in this the
hydrocele attracted but little attention until after the
patient had been ordered to relinquish the truss. It
occasioned him some alarm at first, for he supposed
that a relapse of hernia had taken place; but the symp-
toms disappeared in a few weeks. (Case V.)
An Agent for Dr. CHASE mentions another similar
case, but it appears, from the slender amount of evi-
dence heretofore obtained, that this form of hydrocele
is of short duration, and of no material importance.
In the very old and extensive ventro-inguinal hernia
described in Case I., there was an alteration of texture
observable on the side corresponding with the hernia,
both in the spermatic cord and the testicle, the latter
being almost destroyed by absorption. The Chairman
of the Committee, by whom these parts were most
cautiously examined, is decidedly of the opinion that
this change could not have been induced by the pressure
of the wooden truss-blocks employed, defective as some
of them were, because it is unreasonable to suppose
that such results could have followed an embarrass-
ment in the circulation of the cord, in the short space
of time during which the hard blocks were in use, with-
out occasioning pain or inconvenience to the patient.
8

66
REPORT ON HERNIA.
It is fair to conclude, then, that as the condition of the
testicle had never been perceived by the patient until
pointed out by the Committee, the absorption was the
result of the long continued action of the ill supported
intestines, together with the occasional pressure of ill
applied trusses upon the pubic bone.
The Committee are, therefore, of opinion that there
exist no physiological objections to the use of the
Ventro-Inguinal Block of Dr. CHASE, which are not
equally applicable to all known means of retention in
ventro-inguinal hernia: that this block is more accu-
rately adapted to the form of the pelvis, and the parts
on which it is intended to act, than any pad or block
previously in use, and that it escapes the objections
felt to the Ventro-Inguinal Block of Dr. Hood, by the
greater regularity of its arched form, and the absence
of any angularity or other peculiarity of shape designed
for the production of irritation.
The only peculiarity of the Ventro-Inguinal Truss
of Dr. CHASE, consists in the form of the block. In
every other particular, it is identical with the Inguinal
Truss. But, in the application of the instrument, it
is necessary that the perineal strap should be secured,
at its anterior extremity, to the button on the end of
the block-slide, and not to that on the anterior extre-
mity of the spring.
To the complete instrument, as it has been actually
employed during the last year, the Committee may

REPORT ON HERNIA.
67
safely apply the same language used in concluding their
remarks on the Inguinal Truss.
CHASE'S FEMORAL BLOCK WITH ATTACHMENT.
a
m
m
20
t
T
6
19
d
t
shem
FIG. 19. The letters from a to h, inclusive, have the same reference as
in fig. 10.
k A window in the anterior extremity of the main-spring.
1 The iron neck of the block-slide, continued along the main-spring for
some inches and seen through the window k.
mm Two broad-headed screws of the spring-adjustment, securing the
flattened extremity of the iron neck to the main-spring, and, when
loose, permitting it to slide on the main-spring.
FIG. 20.-A longitudinal section of the femoral block.
The comparative rarity of femoral hernia, and the
fact that a large proportion of the cases of this class
occur in females, have prevented the Committee from
receiving testimony upon a sufficient number to form
a safe basis for calculation in estimating the value of
instruments by practical tests alone; and they feel un-
der the necessity of treating this branch of their subject
chiefly as a mechanical question.
Even the anatomy of femoral hernia has not been
very well understood until recent times, and this fur-

68
REPORT ON HERNIA.
nishes the only reasonable excuse for the fact that, no
truss expressly designed for the treatment of this va-
riety of hernia has ever been strongly pressed upon
the attention of the profession. Many trusses have
been indeed advertised as applicable to all the forms
of hernia;-a degree of pretension carrying with it the
proofs of its own fallacy;-and certain works on sur-
gery contain directions for slight modifications in the
form of the pads, the curvature of the springs, and the
mode of application of inguinal trusses, to adapt these
instruments to cases of femoral hernia; but your Com-
mittee cannot recall any apparatus entitled to the name
of a femoral truss, (the invention of Dr. Hood being
not a truss, but simply a block intended to be added
to the spring of one of the common trusses under cer-
tain circumstances) prior to the construction of the
instrument of Dr. CHASE, which is now under exa-
mination.
It is proper to recall the attention of the Society to
a peculiarity already pointed out as common to all the
trusses previously in use, and to the femoral block of
Dr. Hood. The pad or block invariably covered not
only the site of hernial tumour, but also a portion, and
generally a considerable portion, of Poupart's ligament.
The pads or blocks which act in the manner above
described cannot effect any great certainty of retention
unless the ligaments be made to yield, and the neck
of the hernial sac become pressed against the pubic
bone with considerable firmness. In the opinion of
your Committee, the degree of pressure required to
accomplish this purpose would exceed the power of

REPORT ON HERNIA.
69
any truss-spring, and the capacity of endurance pos-
sessed by the patient, or that of the parts acted upon
by the instrument.
All the instruments employed prior to the invention
of Mr. Stagner are liable to another objection. They
press upon so large a surface, that when employed in
femoral hernia they are necessarily liable to displace-
ment in the extensive motions of the thigh.
When the Committee view these remarks, in con-
nexion with the fact that they have met with no de-
tailed and satisfactory records of the radical cure of
femoral hernia, by instruments, prior to the year 1835,
they are strongly induced to conclude that, no truss
employed before the invention of that of Dr. CHASE
was capable of securing and maintaining that perfect
retention of the last portion of the bowel beneath Pou-
part's ligament, which, by the hypothesis adopted in
this Report, is indispensably necessary to the radical
cure of this form of hernia.
It will be naturally asked, why, if the retention has
always been imperfect or inconstant, have so many
patients, labouring under femoral hernia, been secured
for years against strangulation.
The reply does not appear difficult. The older
trusses, with soft pads, when arranged with great care,
were quite capable of closing all that part of the her-
nial sac which lay below Poupart's ligament; and if,
during exertion, or unusual flexion of the thigh, a small
www

70
REPORT ON HERNIA.
portion of intestine was accidentally protruded into the
sac, the pressure of the pad must have acted as the
best of all modes of taxis, the moment that the exer-
tion ceased or the position of the limb was changed.
This action would tend to confine the protrusion almost
constantly to the femoral canal, which, being very short
and narrow, cannot accommodate a sufficient amount
of intestine to produce much danger of strangulation,
or to arrest the passage of alvine matter; yet the
frequent presence of even minute portions of intestine
in the canal, would effectually prevent the contraction
of the orifice and destroy the hope of radical cure.
The belief that trusses with soft pads do not actually
retain femoral hernia, receives additional support from
the symptoms of abdominal uneasiness, indigestion,
chronic pains, &c. which are usually made a subject
of complaint with those who are treated by such in-
struments both in this kind of hernia and in the in-
guinal varieties; symptoms which speedily disappear
in the latter, when the retention is made accurate and
constant by the instruments already described.
It appears, then, that Dr. CHASE in attempting the
construction of a novel truss peculiarly adapted to
the treatment of femoral hernia, ventured upon un-
trodden ground. We will examine the result.
clatense
yel doldu

REPORT ON HERNIA.
71
de
16
FIG. 21.-CHASE'S FEMORAL AND UMBILICAL TRUSSES,
APPLIED.
ou of
es
2
.21
hate
sds to
(a) Of the Femoral Block.-At the time of the Pre-
liminary Report, Dr. CHASE was in the habit of employ-
ing, for femoral hernia, a block in all respects similar,
except in size, to that designed for common inguinal
hernia. This was applied in such a manner as to act
entirely below Poupart's ligament; and, when sunk by
the absorption of the subcutaneous fat, &c. its upper
extremity tended to oppose directly, and therefore
powerfully, the descent of the intestine beyond the
margin of the ligament; but it was abandoned soon
after the presentation of the report, when the doctrine
of cure by irritation was shaken by the course of the
investigations; and it was suggested that possibly a
block could be invented, which, by becoming imbedded

72
REPORT ON HERNIA.
in the integuments, might act by means of a suitable
prominence beneath the edge of Poupart's ligament,
and by pressing the soft parts directly upward, might
arrest the bowel at the edge of Gimbernat's ligament,
so as to render the retention as accurate as that ob-
tained in inguinal hernia. This suggestion led to the
invention of the femoral block mentioned in the note
of the Chairman, already quoted. It is very difficult
to describe the form of this block, and the Committee
will refer to the treatise of the inventor for the best
description and an excellent wood-cut representation
of it. By considering the mechanical principles of its
action, together with the only case fairly before the
Committee in which it has been employed, (Case X.)
it is deemed safe to recommend it as preferable to any
pad or block previously employed in this variety of
hernia. It is calculated to preserve its position more
accurately than the one before in use; it is not liable
to become disturbed by the motions of the thigh; and
it gives support in a direction which enables it to act
at the greatest mechanical advantage. How far it may
answer the special purpose of its construction, by en-
tering under the fold of Poupart's ligament and acting
almost directly on the femoral ring, the Committee will
not venture to judge upon the evidence of a single
case. The report of Dr. CHASE as to its result in
other instances, is favourable, but neither that gentle-
man nor the Committee regard it as having acquired
the highest degree of perfection of which it is capable.
It will, probably, undergo further modification.
(b) Of the Block-Attachment.-The extreme accuracy

REPORT ON HERNIA.
73
desirable in the adjustment of the small femoral block,
renders the mode of attachment a matter of great im-
portance. Dr. CHASE has succeeded in reaching, in
this respect, a degree of perfection much higher than
that attained by any of his predecessors. The rela-
tion of the femoral ring to the parietes of the pelvis
varies in different individuals to a much greater extent
than that of the abdominal canal, and its variations
are not so nearly confined to one right line. The soft
iron neck of the block-attachment in this truss is bent
at a right angle, so as to place the long diameter of
the block in a position perpendicular when the patient
stands erect. In this position the motions of the block-
slide, which are similar to those observed in the pre-
ceding trusses, adapt the block to the height of Pou-
part's ligament with great nicety; but to meet the
peculiarities of individuals in regard to the distance
between the wing of the ilium and the femoral ring
another arrangement is necessary. There is a fenes-
trum, two inches in length, in the anterior extremity of
the spring; and the soft iron neck, instead of being
permanently secured to the spring, is elongated two or
three inches, curved, flattened, and attached to the
spring by means of two screws, which pass through
the fenestrum, and, when loosened, play freely therein,
so as to allow the block to approach or recede from
the mesial line to any required degree. This double
adjustment is simple, secure, and perfectly accurate.
There is no other peculiarity in the spring or ap-
pendages of this truss, but the perineal strap is
always secured in front to the button on the bottom
of the block-slide.
9

74
REPORT ON HERNIA.
Home
FIG. 22.-CHASE'S DOUBLE TRUSS-PREPARED FOR A
DOUBLE INGUINAL HERNIA.
22
K Jd [ [ ] ]]
11 116
g
a The two common inguinal blocks with their attachments.
b The spring-cover of the left truss terminating in the strap c c c c.
cccc The pelvic strap of the left truss, thrown into loops, and passing
through an opening beneath the base of the attachment of the strap
on the right side at e, like the flexor tendons of the last phalanx of
the fingers through the terminations of those of the second phalanx.
d The spring-cover of the right truss terminating in the strap ff ff.
e The site of the commencement of the pelvic strap of the right truss,
secured by the edges to the spring-cover, but permitting the left pel-
vic strap to pass up from under its base so as to become superficial
in the rest of its course; this arrangement being concealed by the in-
strument.
ffff The pelvic strap of the right truss thrown into loops.
ggggg Loops confining each pelvic strap respectively to the spring
cover of the opposite truss.
h The two springs seen one behind the other, and naked, between the
ends of the spring-covers.
kk Dotted lines representing the spots where the spring of each truss
terminates within the spring-cover of its fellow.
7 A dotted line representing the proper position for the back-pad.

REPORT ON HERNIA.
75
Great difficulty has always been experienced in
treating double hernia when the bowel protrudes on
both sides of the lower boundary of the abdomen.
The double trusses which have been from time to time
constructed, have been formed by encircling the back
and sides of the pelvis with a single spring armed with
a truss-pad at each extremity; or the two halves of
the spring, divided at the spine, were connected by
means of a slide or hinge. Notwithstanding the many
modes of adjusting the pads in the attempt to effect
their accurate adaptation, it was found, practically,
that the rigidity of these instruments rendered it im-
possible to secure the springs properly upon the pelvis
or the pads upon the hernial orifice, and none of them
have ever obtained the sanction of the profession.
The imperfect action of the double trusses, drove the
surgeon to the necessity of employing two single
trusses in the treatment of double hernia; but here,
again, the treatment is surrounded by difficulty; for the
interference between the springs behind, and the twist-
ing of the two straps round each other in front, render
retention uncertain, and produce great annoyance and
disgust to the patient, from the clumsiness of the ma-
chinery.
Since the Preliminary Report was read, Dr. CHASE
has invented the admirable instrument now for the first
time presented to the Society. It is an association of
two single trusses, so combined as to be perfectly in-
dependent in their action, without the slightest mutual
interference, yet so associated by means of the straps
and loose spring-covers, that they present the appear-

76
REPORT ON HERNIA.
ance, and act with all the convenience of a single in-
strument. Each spring, at its posterior extremity, re-
enters the spring-cover of its fellow, and the strap of
one truss passes smoothly through a passage beneath
the commencement of that of the other, so that both
sides appear symmetrical, as far as the springs and ap-
pendages are concerned, and the straps do not in the
slightest degree embarrass each other. As the pecu-
liarities of this instrument are confined to the spring-
covers and straps, which are suited alike to the trusses
for inguinal, ventro-inguinal, and femoral hernia, the
instrument can be adapted; at a moment's notice, to
any possible combination of these three forms of the
disease, so long as the varieties exist on opposite sides
of the abdomen.
The Committee cannot speak too highly of this
beautiful invention, but it may be safely permitted to
speak for itself.
FIG. 23.-CHASE'S UMBILICAL BLOCK AND ATTACHMENT.
b
23
24
B
00
a
nobregab
refer

REPORT ON HERNIA.
77
a The anterior end of the spring, with the same kind of spring-attach-
ment as in the femoral truss.
b The circular block.
c The circular block-rider.
d The circular iron disk supporting the block-rider.
e e Two button-headed screws attaching the rider to the disk, and serv-
ing at the same time to secure the strap.
FIG. 24.-Section of the circular block.
The peculiarity of the block in this instrument con-
sists in its having a central prominence on the convex
face, which prominence is a segment of a much smaller
sphere than that which furnishes the margin of the
block: it is thus made to correspond more nearly to
the form of the parts about the umbilicus, while its
effuse margin prevents the danger of too great absorp-
tion under its pressure.
The block with its brass rider is attached to a cir-
cular expansion on the anterior extremity of the soft
iron neck, by means of two screws, one placed vertically
about an inch above the other, and so formed as to
serve at the same time as buttons, on which the strap is
secured by means of a double series of eyelet holes.
Of course, then, there is no mobility in this attachment.
The only adjustment required is in a circular direction,
and is accomplished by means of the following ar-
rangement. The spring is placed horizontally. Its
anterior extremity is provided with a fenestrum five
inches in length. The soft iron neck is about six in-
ches long, and is secured to the spring by two screws
which pass through the fenestrum, and may be made
to slide therein precisely as those do which are seen
in the corresponding part of the Femoral Truss.

78
REPORT ON HERNIA.
The back-pad is made oblong instead of round, and
is supported by two leather loops instead of one, as in
the other trusses. It is arched transversely, and is
about six inches long by four inches wide. This form
is required to give support to the spring on the broad
and flattened portion of the back.
This truss has secured the perfect and constant re-
tention of the bowel in all the cases seen by the Com-
mittee, two of which were of a peculiarly unfavourable
character. In Case XIX. the orifice by which the
bowel protruded, extended for two and a half inches in
the longitudinal direction, and one and a half in the
transverse direction. The patient was enormously
loaded with fat, and a block six inches in diameter was
required to effect the retention.
In Case XXIV. the peculiar form of the sac and its
enlarged tegumentary covering occasioned much em-
barrassment, as will be seen on reference, but it did
not prevent success.
The only accident observed to result from the use
of this instrument has been the slight excoriation or
mucoid transformation of the skin where it is thrown
into folds in consequence of the redundancy occasioned
by the sac; an accident observable in bad cases only,
one which is easily rendered tolerable by dusting the
part with carbonate of zinc or other dry powders, and
one, moreover, which is not dependant upon the cha-
racter of the instrument employed. The Committee

REPORT ON HERNIA.
79
deem it, therefore, almost unnecessary to state their
decided preference of this instrument.
VI.-OF THE UMBILICAL BELT.
The Committee will not detain the Society with any
particular notice of this contrivance; but will merely
state, in passing, that it is composed of a broad band
of elastic caoutchouc tissue, armed with the block em-
ployed in the umbilical truss, and secured by means of
a peculiar buckle. It possesses all the excellencies of
the best hernial belts, with better security against
creasing than any of its predecessors. But your Com-
mittee deem all belts objectionable in the treatment of
umbilical hernia, because it is impossible by such ma-
chines to effect the necessary pressure at the umbilicus
without embarrassing the motions of the ribs and dia-
phragm in respiration; for the band acts equally at all
points, exerting as much force in the lateral as in the
antero-posterior direction. When the functions of the
parts subjected to the action are taken into the calcu-
lation, it is evident that this arrangement is one ex-
ceedingly objectionable in a mechanical point of view.
In the trusses, on the contrary, the elastic spring effects
the necessary retention by its pressure on the back-
pad and the block, which precisely counteract each
other, and no more lateral pressure is required of the
spring or strap than is requisite to protect the instru-
ment from displacement by the friction of the clothes.
In condemning the umbilical belt of Dr. CHASE, toge-
ther with all its predecessors, the Committee feel much
pleasure in stating that after practical tests which they

80
REPORT ON HERNIA.
did not deem necessary, it has been frankly relinquished
by its inventor, although it has effected radical cures in
two cases. (See Cases XX. and XXIX.)
One point of importance connected with the question
of the retentive power of trusses is the constancy with
which they are worn. The instruments of Dr. CHASE,
regulated as the force of the springs now is, are worn
day and night by the patients, and after the first week,
very rarely continue to give any inconvenience.* In
order to enable patients to bathe and swim without
danger of protrusion, this gentleman has contructed
truss covers of India rubber cloth, the varnished side
turned toward the instrument, which are designed to be
used temporarily at watering places. They have been
found to fulfil most perfectly the object of their con-
struction.†
As it regards the retentive power of the trusses
which have been approved by the Committee, it has
been tested in various manners, and severely. Some
of the patients, while wearing them, have followed the
most trying labours of the harvest field and the marble-
yard; others have travelled hundreds of miles on horse-
back, over mountainous countries. The subject of the
* For directions in the application and use of trusses see "Chase
on Hernia," Chap. VIII. P. 127.
† These instruments should be worn at all times, whether in
bathing at public resorts or in the private bath, during the use of
the truss. A neglect of this may produce a return of the disease.
-See Chase on Hernia, p. 136.
H. C.

REPORT ON HERNIA.
81
worst incurable case of ventro-inguinal hernia,-which
had destroyed his usefulness, notwithstanding his en-
deavours to retain the bowel by means of other in-
struments, has since resumed his labours as a steve-
dore and sailor; some have followed the chase, and
leaped fences and dykes, gun in hand, &c., &c.; yet,
since the instruments were brought to their present
high state of perfection, the Committee know of no
instance of protrusion under these exertions. In one
case only, the bowel has escaped after the final adjust-
ment, in consequence of carelessness on the part of the
friends of the patient, a young infant. (Case XXV.)
And in another instance, the insanity of the patient led
to the removal of the truss. (See Prel. Rep. Note II.)
Your Committee deem any further comment on the
retentive power of the trusses of the second class alto-
gether unnecessary. These instruments certainly fulfil
to admiration the two grand requisites which they con-
sider necessary to bring the chances of radical cure in
hernia to a maximum.*
* "If, however, the irritation be so important as it is deemed by
some, there is no necessity, with your apparatus, to resort to any
other application than the truss, the blocks of which may be made
to produce the effect to any extent required.
"You have done me the honour to ask my individual opinion on
the modus operandi of your trusses, after the examination of nume-
rous cases. It is frankly this:
"They owe almost all their very remarkable success to their per-
fect retentive power, which is probably aided by a little moderate
irritation from pressure in umbilical, direct, and ventro-inguinal
hernia, possibly in common inguinal hernia, but not in femoral
hernia. It is scarcely practicable to apply the instruments without
10

82
REPORT ON HERNIA.
The extensive remarks already made on the effects
on the tissues, produced by the first class of trusses,
render it unnecessary to enter at length on those at-
tending the use of the instruments just described; the
institution of a fair comparison will be sufficient.
The irritation occasioned by the blocks of Dr. CHASE
is much less severe than that observed when blocks
of the first class are employed. That they are capable
of producing much irritation, if such a result be desired,
is obvious from the history of the case to which refer-
ence was made in the last paragraph; in which case
inflammation was intentionally brought on, in order to
test the powers of the instrument. More or less pri-
mary redness has been observed in nearly all the cases,
though there have been some in which it could not be
distinctly recognised. Except in the case just men-
tioned it has been always inconsiderable and evanes-
cent, unless the patient had increased it by disobedience
to orders. It has never shown that disposition to pro-
duce callosity around the margin of the block, which
was noticed in some of the cases treated with other
instruments. The absorption consequent on the long
continued application of the block takes place more
producing as much irritation as I should think advisable, and I
have been increasingly pleased with their effects, as your blocks
have been gradually improved from time to time, in such a manner
as to remove the danger of inflammation, and to reduce the irritation
to a moderate redness. They are now convenient, pleasant, and
safe in their action."-Extract from Dr. R. Coates's private letter
to Dr. Chase on the action of his trusses. See Chase on Hernia,
p. 125.

REPORT ON HERNIA.
83
slowly, and seldom brings the skin into quite as close
approximation to the tendons beneath. In very fat
subjects, the block sometimes becomes deeply embed-
ded, but their size and generally rounded form appear
to prevent all danger of absorption of the tendons un-
der the pressure. The secondary hyperemia, resulting
from the functional debility of the compressed capilla-
ries, is noticed in every case, but in less degree than
when other hard blocks are used, nor does it continue
so long after the removal of the instrument. The Com-
mittee have never seen inflammation supervening after
the subsidence of the primary irritation. It is remark-
able that in many cases, the capillaries have partially
recovered their tone under the pressure of the blocks,
and the secondary hyperemia has been diminished after
the trusses have been worn for a considerable time.
The redness resulting from this cause is of course no-
ticed in patients who resort to any species of truss,
and the Committee, not being willing to trust to their
memory of past experience unaided by notes, cannot
institute a fair comparison in this respect between the
effects of soft pads and the blocks of Dr. CHASE. Their
impression is that the effects of the latter are more
obvious than those of the former, but that the differ-
ence is of no practical importance. Attenuation of the
skin has not been remarked in any patient employing
Dr. CHASE's trusses in their present state of perfection.
Definitively; the Committee have been unable to
trace any distinct connexion between the superficial
effects of these instruments, and the changes perceived
in the tendinous margins of the hernial orifices noticed

84
REPORT ON HERNIA.
during the time of their employment, changes which
will next claim our attention.
The absorption of the subcutaneous fat, &c., follow-
ing the use of these trusses as well as those of the first
class, being unaccompanied with any thing like adhe-
sion between the integuments and the tendons beneath,
the thin skin of the scrotum is reverted beneath that
of the inguinal region with great facility; and in her-
nia located there, the precise condition of the edges
of the hernial orifices may be examined by the finger
in the most satisfactory manner, and the following
results have been obtained by the inspection of a large
number of cases.
The orifices of very large ventro-inguinal hernia are
found to contract rapidly after the perfect adjustment
of the block, so that a few weeks or months will some-
times suffice to reduce an opening which will receive
three fingers, with the skin of the abdomen inverted
to less than one half its original area. (See Cases I.
and XI.) These extreme cases have generally been
found in persons advanced in life; and, as the length
of time which has elapsed since the very commence-
ment of our investigations is less than three years,
many of the cases presented to us are necessarily of
recent date, and the question of radical cure remains,
in them, still undetermined-if indeed it be reasonable
to entertain a thought of such an occurrence under
circumstances so extremely unfavourable. But this
may be safely said:-The contraction continues upon
the increase in all the cases yet incomplete, and no

REPORT ON HERNIA.
85
assignable limit short of the natural dimensions of the
external ring have been ascertained! The instances
referred to, will furnish the Society with a tolerable
idea of the importance of the results in the few cases
which have been under observation for twelve months
or more.
While this contraction is taking place, the tendinous
margin of the ring appears to increase very gradually
in thickness, and the impression is produced that the
substance of the tendon is enlarged by an interstitial
deposition. This deposition is decidedly soft at first,
but though rendered by degrees more firm and resist-
ing, it does not distinctly assume the well marked cha-
racters of the purely fibrous expansion in which it is
formed, within any period yet determined, at least so
far as can be ascertained by the sense of touch.
In common inguinal herniæ, even when they have
become nearly direct, and in ventro-inguinal hernia of
recent date, or moderate extent, the contraction and
thickening continue on the increase until the affected
ring is often rendered smaller, and, sometimes, much
smaller than in the normal condition. (See Cases V.
and XXIII.) The progress of the finger in the attempt
to penetrate the external ring is then resisted with de-
cidedly more firmness on the affected than on the un-
injured side, and this is obviously the case in one in-
stance in which there appears to have been congenital
weakness of the parts on both sides. (Case III.)
In common inguinal hernia, the upper orifice at the

86
REPORT ON HERNIA.
internal ring is entirely beyond the reach of examina-
tion, and it is only by analogy that we can arrive at
any inference with respect to its condition. The same
remark holds good in relation to the condition of the
orifice in femoral hernia.
It is unnecessary to point out the influence which
the changes just described must exert in preventing the
exit of the intestine. They will be understood by the
Society without further comment.
The Committee do not feel called upon officially to
express any theoretical opinions as to the mode in
which nature accomplishes the contraction of the ten-
dinous orifice in hernia when treated by means of the
instruments now under notice, but it is their duty to
state that they cannot trace the agency of any irrita-
tion produced by the truss-blocks in the history of these
changes. The letter of the Chairman on the modus
operandi of Dr. CHASE'S apparatus, as published in the
treatise of the latter gentleman, contains a full account
of the opinions of one of the members on this subject,
and the remainder of the Committee are not prepared
to combat the positions therein maintained. If the
theoretical views alluded to be correct, the singular
fact of the contraction of the ring to a size still smaller
than the natural one would be accounted for, either by
supposing that there remained a persistent callosity
about the orifice, like that which sometimes continues
long around the track of an obliterated fistula, or that
the union of ruptured fibres formed an irregular tendi-
nous mass, like the surplus amount of new bone which

REPORT ON HERNIA.
87
is produced by the reuniting of a fracture. It is not
impossible that both these causes may contribute to
produce the appearances described, and it becomes,
therefore, a question of much interest to determine
how long the undue firmness of the ring may continue;
or, in other words, how far the deposition about the
margin is provisional, and how far it is permanent.
It would be certainly surprising, though by no means
impossible, that the cure, when effected, should give
the patient better protection than he enjoyed before the
accident. This point can only be decided after several
years of observation upon the same cases, and it is
recommended to the attention of the Society.
The sac, when thin or small, generally escapes ob-
servation, and is probably obliterated or returned before
the conclusion of the treatment; but when large and
thickened, it is found continually contracting and ap-
proximating to the orifice by degrees. It is not always
wanting when the tests of radical cure are applied with-
out producing protrusion: while it remains, it is gene-
rally found more or less distended with fluid. In the
letter of the Chairman, already referred to, there will
be found a notice of a curious case of umbilical hernia,
in which the sac remained, and presented its connexion
with the cavity of the abdomen long after protrusion
had been rendered apparently impossible by the con-
traction of the orifice, under the use of a block of lead,
moulded to the form of the part.* One case of inguinal
hernia occurring in the practice of Dr. CHASE, was
* Chase on Hernia, p. 109.

88
REPORT ON HERNIA.
attended with somewhat similar circumstances. (Case
V.) These may be regarded as remarkable exceptions
to general laws, but they are sufficient to establish two
important positions; first, that a perfect occlusion of
the neck of the sac is not indispensably necessary to
the permanent retention of the bowels by natural means;
and, secondly, that the changes in the tendinous mar-
gin of the orifice are not invariably productive of such
occlusion. The latter of these positions furnishes a
most powerful argument against the doctrine that the
changes just mentioned result from the irritation pro-
duced by the truss-blocks.
After all that has been stated, the Committee feel
themselves fully warranted in the following conclu-
sions.
1. The retentive power of solid blocks is, cæteris
paribus, superior to that of soft pads in the treatment
of hernia, as has been already stated in the Preliminary
Report.
2. The chances of radical cure depend upon the
perfection and permanence of the retention.
3. The perfection and permanence of the retention
depend-first, upon the mechanical action of the in-
struments; and, secondly, upon the power of the parts
affected to bear that action without danger of physio-
logical accidents of sufficient importance to interfere
with the treatment.

REPORT ON HERNIA.
89
4. All the instruments with solid blocks contrived
before the recent inventions of Dr. CHASE, are de-
cidedly liable to important mechanical objections, and
all of them, with the exception of the Rachet Truss,
are moreover capable of producing physiological acci-
dents of sufficient importance to interfere with the
treatment.
ad med
bog
Ep
5. The construction of the Rachet Truss is such as
to render retention uncertain even in ventro-inguinal
hernia, to which form of the disease alone, it is tole-
rably well adapted.
6. The instruments of Dr. CHASE have effected the
permanent and accurate retention of the intestines in
every case of hernia observed by the Committee,
without material inconvenience to the patient, and
often under trials more severe than are usually ven-
tured upon by those who wear other trusses; trials
which would be imprudent with any other apparatus
known to the Committee.
7. If we except the Femoral Truss, these instru-
ments have stood the test of much practical applica-
tion without superinducing any physiological accidents
of sufficient importance to interfere with the treat-
ment.
8. The mechanical principles upon which the femo-
ral truss is constructed appear highly ingenious and
promising; and unless this instrument should be found
hereafter to be productive of important physiological
11

90
REPORT ON HERNIA.
accidents, it must take precedence of all other modes
of treating this variety of the disease. No such acci-
dents are yet known to have been produced by its em-
ployment; but the Committee have not enjoyed the
opportunity of personal inspection in a sufficient num-
ber of cases to determine general results, nor do they
deem it proper to receive evidence from any other
quarter in discharging the trust reposed in them by
the Society.
The Committee are induced by the foregoing con-
clusions to recommend, in strong terms, the instru-
ments of Dr. CHASE to the confidence of the profes-
sion, as the best known means of mechanical retention
in hernia, and as furnishing the highest chances of
radical cure.
The Committee have not deemed it necessary to in-
stitute a numerical comparison between the degree of
success attending the use of soft pads and hard blocks
in the treatment of hernia; for the testimony of the
highest surgical authorities, their own experience, and
the general feeling of the profession, sufficiently prove
the rarity of the cure of hernia by any of the appa-
ratus in use previously to the commencement of the
present investigation. They think they have done the
most ample justice to the claims of the older trusses
by the statements contained in the Preliminary Report,
(p. 324,) statements which are less opposed to the
claims of common trusses than are the opinions of
Professor Hey of Leeds, Tavernier, Abernethy, Sir
gotoicalq
on to ex

REPORT ON HERNIA.
91
Astley Cooper, and many other European authorities
of the highest class.*
Before endeavouring to estimate the chances of
radical cure by the use of Dr. CHASE's trusses, it is
necessary to determine what is meant by a radical
cure.
A variety of facts have been collected by Dr. CHASE
which tend to show that vices of formation predis-
posing to hernia are sometimes hereditary in families,
and that congenital weakness of one abdominal ring
is not unfrequently accompanied by a similar condition
of the other ring, and also of the umbilicus.† In cases
* But the slightest examination into the writings of the most
eminent surgeons will be sufficient to convince the reader that there
is very little dependence to be placed in the retentive power of
any of the trusses now in general use as a means of radical cure,
unless in cases of young children.
The sweeping denunciations uttered by PERCIVAL POTT, against
those who pretend to accomplish this desirable object by mechani-
cal contrivances, are scarcely weakened by the faint hopes of occa-
sional success to be found in the works of LAWRENCE, RICHTER,
SIR A. COOPER, DORSEY, &c., and the mechanical treatment of
Rupture, as prescribed by the most experienced men in the pro-
fession, may be summed up in the pithy sentence of ABERNETHY.
"You return it (the bowel); put a truss on it, and keep it on."
Some of those who employ astringent applications, boast of
greater success; but if the results which they report had been fully
borne out by further experience, it is very improbable that the dis-
ease would have continued to be regarded so hopeless in cha-
racter."-Chase on Hernia, p. 104.
† See Chase "On Hereditary Hernia," in Treatise, Chapter XI.
p. 192.

92
REPORT ON HERNIA.
of the latter description, hernia is occasionally ob-
served consecutively or consentaneously in each of
these positions. Facts of this nature have probably
given rise to the opinion expressed by some recent in-
ventors of double trusses for the treatment of single
hernia; namely, that the retention of a hernia on one
side is like to produce a hernia on the other. The
Committee see no foundation for this opinion, unless
the strength of the spring of the truss be made much
greater than necessary, or in cases of enormous her-
niæ, in which the bowels have been allowed to remain
protruded for so long a time that the abdominal mus-
cles have become accustomed to an unusual degree of
contraction.
Granting, however, for the sake of argument, that
the liability to a consecutive hernia is increased by the
retention of one already existing, the use of the
double trusses in single hernia would still be objection-
able, because the whole amount of pressure to which
the abdomen is subjected by them is obviously at least
twice as great as is necessary to effect retention, and
hence the danger of consecutive umbilical hernia from
the action of the instrument is at least doubled. It is
obviously a task of extreme difficulty, if indeed it be
not impossible, to guard against the occurrence of her-
nia at all its usual orifices, and the number of con-
secutive cases will probably be found to form a very
small per centage on the whole number placed under
treatment. The Committee, therefore, disapprove of
the employment of trusses as a prophylactic measure.*
* An attempt was made in 1835 to introduce an instrument of

REPORT ON HERNIA.
93
Returning from this apparent digression, it does not
seem proper to consider the consecutive occurrence of
hernia in one situation as a disproof of the radical
cure of a previous hernia in another situation.
As all men appear to be subject to this kind of acci-
dent under the action of certain forces, it would seem
at first sight unreasonable to expect any course of
treatment to effect a degree of security against the re-
currence of the protrusion in any individual, greater
than that which existed prior to its first occurrence;
and hence a cure may be fairly considered radical,
without supposing the part affected relieved from the
possibility of a reappearance of hernia at the same
spot, under all possible circumstances and casualties.
log
this description into use in this and other cities in the United States,
upon the supposition that in single ruptures support on both sides of
the pelvis was required. This truss, known as Hittle's, is thus
noticed in the Journal of the FRANKLIN INSTITUTE.
"It is assumed by the patentee that if pressure is made on one
side only, this pressure tends to rupture the opposite side, an
opinion not at all sustained by experience, or founded in reason."
-Vol. XVI. p. 385.
In accordance with the views of the Committee, it may be stated
that I have carefully watched the action of trusses in more than
two hundred cases, and have never seen a rupture produced by the
action of a well regulated instrument. It is by no means unusual
among debilitated and worn out constitutions, to find a general
weakness in the inguinal regions, and more particularly among
those who have laboured under hernia for years, and have worn the
semicircular springs which give support at two points only.
Patients of this description who employ the semicircular springs of
Hull and others, should always wear the Russian belt as a support
to the abdominal muscles.-H. C.

94
REPORT ON HERNIA.
The cases already mentioned in which the external
ring has been contracted to a greater degree, and has
been rendered firmer than natural during the course of
treatment, tend to show that in certain instances the
resistance to protrusion is greater after the cure than
it was before the accident; and hence, that hernia from
future injury would be more likely to occur elsewhere
than at its first location. It is not unreasonable to
suppose that this increased security may be sometimes
permanent, but years of observation are necessary,
as has been already stated, to determine how general
the applicability of the rule may be.
In answer to the quere, then-What is meant by a
radical cure?-the Committee conceive the following
reply the fairest and most rational that can be
offered.
A cure is radical, when the tendinous and fascial
barriers to the egress of the bowel are brought or re-
stored to their normal or original firmness and power
of resistance.
The only means by which such a result can be
tested, are the firmness and resistance of the ori-
fice when placed where it is subject to examination,
and the absence of all appearance of protrusion after
the truss has been relinquished for some weeks or
months, and after the patient has pursued his usual
avocations, resorting frequently to more severe exer-
cises, such as coughing, leaping, fatiguing walks,
swimming, lifting, dancing, riding on horseback, &c.

REPORT ON HERNIA.
95
A variety of causes have tended to reduce the num-
ber of cases in which the whole history of the acci-
dent, the treatment and the result has been placed
within reach of the Committee. Among the most
important of these may be mentioned, the extreme un-
willingness of many patients to relinquish the use of
the truss, even when urged to do so by the united ad-
vice of their surgeon and the members of the Commit-
tee; the removal of many patients to a distance after
having been a long while under treatment, but before
it has been deemed perfectly safe to lay aside the in-
strument; and the unwillingness of some persons to
submit to the necessary examinations;-yet, notwith-
standing these difficulties, the amount of indubitable
evidence actually furnished on the question of radical
cure has been considerable, though none has been
relied upon as a basis for conclusions, except such as
has been furnished by the actual examinations of one
or other of the members of the Committee, and the
testimony of the patients themselves.
All the individuals who have relinquished the use
of the trusses approved by the Committee, after hav-
ing worn them for six months or more, and who have
been afterwards examined by a member or members
of the Committee, have been subjected to the neces-
sary tests, and are believed to be radically cured in
the sense of the foregoing definition. A still larger
number who are yet under treatment give promise of
a similar result, and those who refuse finally to relin-
quish the instrument on the advice of their surgeon,
present, in the firmness of the rings, and in the ab-

96
REPORT ON HERNIA.
sence of protrusion under exertions performed when
the trusses are temporarily removed, very strong
grounds for believing the cure to be radical in them
also.
Two cases only of old ventro-inguinal hernia, oc-
curring in persons of nearly sixty years of age, and
so large that the orifices admitted of the free passage
of two or more fingers within the reverted skin, have
been deemed incurable; but even in these, the contrac-
tion of the rings, and the resistance to protrusion
when the trusses have been removed by the patients
for a few hours, render the impossibility of cure by
no means certain; and it is deemed improper ever to
subject the patients to the tests necessary to deter-
mine the question. The enormous umbilical hernia
which is the subject of note marked Case XIX., is in
all probability incurable.
The cases observed include all the usual forms of
external herniæ, whether resulting from mechanical or
physiological causes; and also, some instances of
double and triple hernia.* The complications which
* Triple herniæ are not uncommonly met with by those who have
considerable experience in the treatment of this affection. One case
of double inguinal and one case of single inguinal accompanied with
umbilical hernia, and one case of double ventro-inguinal with fe-
moral hernia, have recently occurred in my practice. The case of
double inguinal and umbilical occurred in a boy seven years old.
Two cases of inguinal and femoral hernia on the same side has
been met with in the practice of Dr. WARREN, of New Orleans, and
one patient presented himself to Dr. MARTIN, of Havana, Cuba,
labouring under double inguinal hernia combined with femoral of

REPORT ON HERNIA.
97
have not been presented are known to be very rare,
and the Committee therefore feel no hesitation in ex-
the left side. In the fall of 1835, in company with Dr. Cook, of
Westchester, Pa., I examined a gentleman quite advanced in years,
who was labouring under an inguinal hernia of the right side, and
a femoral of the left, which passed down half way to the knee. I
applied an instrument to-day to a lady who has ventral hernia.
She received a kick from her husband ten years ago. The bowels
protruded at three different openings near the umbilicus. She has
tried several of the old trusses to no purpose. Her bowels are
now perfectly retained by an instrument such as is described in
Case XXVIII. of the report.
Dr. Gage, of New York, has also met with one case of inguinal,
combined with umbilical hernia. The following case, marked by
very curious circumstances, occurred in the practice of the last
named gentleman, who has kindly reported it to me.
I quote his
words:
One of my cases, which to me is of great interest, is that of Mr.
P. L., a very worthy man, and one of immense muscular power.
He had double inguinal hernia, the right direct and the left
nearly so. He had tried numerous trusses, none of which, how-
ever strong the spring, would retain the rupture a moment. His
hernial tumours were very large and had rendered him wholly un-
able to attend to his occupation, which was that of a wheelwright.
He had had great trouble in voiding his urine for a long time.
I put on one of your double trusses, which retained the bowel
perfectly. On confining the bowel in the abdomen a very severe
pain seized him in the bladder, and a very urgent desire to pass
water without the ability to pass a drop. In the course of about
four hours, in attempting to urinate, very nearly a gill, by mea-
sure, of stones of the size of small peas passed away with his wa-
ter. They were perfectly round and all of the same size, and of
a light brown colour, and chalky consistence. For two or three
days there were some sandy particles deposited from his urine,
when all these appearances ceased. Since that time, which is
about six months, he has been perfectly free from every appear-
ance and symptom of gravel.
H. C.
12

98
REPORT ON HERNIA.
pressing a strong and, they think, well grounded hope
that a very large majority of the cases of this dreaded
disease will yield to the action of the apparatus of Dr.
CHASE, when under the direction of persons of high
surgical and mechanical abilities.
It has become a subject of regret, since a number
of points of unforeseen interest are found to be con-
nected with the subject, that the Committee have pre-
served detailed notes of only a few of the cases, and
have it not in their power to furnish numerical data
for determining the frequency of the several forms of
hernia, the relative curability, and the time required
for the successful treatment at different ages, together
with many other highly important subjects of inquiry.
This deficiency is in part supplied by the treatise of
Dr. CHASE; and it is understood that a statement of
the results of the treatment in Ohio, from the pen of a
gentleman of high professional reputation, will shortly
appear in one of the western journals. Should these
examples be followed in other places, the science will
be undoubtedly enriched by many curious and import-
ant results.
In their Preliminary Report, the Committee ex-
pressed decided opposition to the employment of trusses
in infants. Candour demands the avowal, that further
observations have shaken their opinion on this subject.
Several cases treated at a very early age, by the in-
struments under notice, have proved that they are
borne without inconvenience in infancy. Some in-
stances in proof of this will be found noted among the

REPORT ON HERNIA.
99
evidence in the Appendix to this Report. The adap-
tation of the trusses to the comfort of children under
three years of age, and their superior certainty of ac-
tion establish their claim to preference over any other
mode of treatment. Their applicability, within the
year, has been successfully tested in two cases; and it
is certain that more force is required to confine the
bowels by any form of bandage or compress, than by
means of a well regulated spring and block. The only
comparative trial of the soft pad and the hard block
in an infant, (Case XXIX.,) has resulted in favour of
the latter; but the Committee feel bound to urge the
necessity of high surgical skill, and extremely careful
attention in dealing with these little subjects.
The time required for the radical cure of an ordinary
case of ventro-inguinal or direct hernia in the adult,
appears to be from twelve to eighteen months. It is
probable that the bowel, in common inguinal hernia, is
rendered secure in a shorter time, but prudence has
prevented the earlier relinquishment of the truss except
in a very few cases. The orifice in umbilical hernia,
appears to contract somewhat more slowly, but all the
varieties recover much more rapidly in childhood.
The evidence, of which circumstantial details are
preserved, will be found in an Appendix to this Re-
port; and a case of high interest occurring in the
practice of Dr. HENRY BOND, of this city, is added to
the list in consequence of its collateral connexion with
the question before the Committee, although no re-
marks will be made upon it on the present occasion.

100
REPORT ON HERNIA.
It will probably form the subject of some comments
on a future occasion, by the Chairman in his individual
capacity.
The Committee will close their labours by recom-
mending to the Society the appointment of a new
Committee, to collect evidence on the several questions
noticed as undecided in the present Report.
All which is respectfully submitted.
REYNELL COATES.
ISAAC PARRISH,
NOTE.
During the engrossment and final reading of the above Report
and Cases, Dr. ASHMEAD, the third member of the Committee, was
prevented from attending its meetings by indisposition and absence
from the city, and his name does not appear among the signatures.
R. C.

Colo. Med. Liby. Asso'n.
101
APPENDIX.
Jowol
Many of the following cases are collated from the Preliminary
and final Reports. Others were noted by the Committee during
their observations embraced in their final report alone. Nothing
has been added or altered except those phrases which were neces-
sarily removed to preserve the connexion of the same cases as
treated in the two Reports.
H. C.
Ventro-Inguinal Hernia, of 10 years standing, from
sudden lifting; age of patient 58 years; imperfect
retention from Chase's Ovoidal Block; contraction
of the ring; Chase's Umbilical Block substituted
for some days; failure of retention; new Ventro-In-
guinal block employed; perfect retention; bowels re-
tained for hours under exercise without the instru-
ment in twelve months; further tests of radical cure
deemed imprudent; truss ordered to be worn per-
manently; alteration of cord and testicle.
CASE I. By the Committee, Oct. 5, 1835.-P. B.
a vigorous seaman, aged 58 years, has been subject
to ventro-inguinal hernia since May, 1825. The bowel

102
APPENDIX.
descends into the scrotum, and the hernial tumour is
said to be enormously large occasionally. The sac
is much thickened and extensive, constituting by itself
no inconsiderable tumour when the hernia is not re-
duced.
The accident occurred suddenly, while raising an
anchor, the patient being at the time submersed in
water. The bowel has never been strangulated. B.
is very subject to attacks of colic, but these appear to
have been unconnected with any mechanical obstruc-
tion of the intestine; as they occurred not less fre-
quently before the accident. A truss with CHASE'S
ovoidal block, has been applied since the 15th of July.
Two attacks of colic have taken place since that time;
and on each of these occasions the pad was removed,
and the hernia descended. The last descent took place
on the 28th of September, and then, for the first time,
the patient was unable to return the hernia without
assistance. He sought aid from Mr. CHASE the next
day, and the intestine was reduced with some difficulty,
produced, as Mr. C. supposes, by the gradual contrac-
tion of the ring under the course of treatment. The
mouth of the sac was originally so large that the skin
could be depressed into the abdomen until the patient
could pass three fingers through the ring. After the
return of the protruded parts, on the 29th ult. he could
not detect the aperture. He has complained, occa-
sionally, of some slight excoriation from the action of
the block, but this has never occasioned severe pain.
Such is the statement given by the man himself, cor-
roborated by Mr. CHASE, and record book of cases.

APPENDIX.
103
The Committee do not think it warrantable, in justice
to the patient, to make any examination of the parts
beneath the block, until time has been allowed for a
more complete condensation of the parts. Mr. CHASE
scarcely anticipates such a cure in this case, as will
ever enable the patient to dispense entirely with a
truss; particularly on account of the nature of his oc-
cupations, which are very laborious.
doold ovo ori
How ca
Oct. 13.-B. appeared before the Committee. A
very considerable descent of the bowel had taken place
from beneath the block. He states that he was yes-
terday engaged on an election frolic, walked a greater
distance than he had done at any previous time for
many years, and drank "a great deal too much." The
truss was removed, the bowel reduced by Mr. CHASE,
and the ring examined by the Committee. The hernia
was direct, and the orifice large enough to admit two
fingers.
Dec. 5.-Since the last date, this patient has been
presented before the Committee twice, his bowel has
been pretty steadily retained by the truss, but another
year, at least, will be required to enable the Commit-
tee to judge of the full effect of the treatment under
such unfortunate circumstances. At present, the case
is regarded as incapable of radical cure by any means,
but the patient enjoys more comfort than he had before
experienced at any time subsequent to the accident;
and he is now able to attend regularly to his business.
Within the last few days he has used a block similar
to the smaller wooden plano-convex blocks, which Mr.

104
APPENDIX.
CHASE employs in umbilical, ventral, and occasionally
in ventro-inguinal hernia. Of the propriety of the
latter change, the Committee will express no opinion.
-Preliminary Report.
This case was drawn up to the 5th of December,
1835, in the Preliminary Report. (Case I. p. 314.)
The plano-convex block, then in use, failed in main-
taining the hernia so well as the ovoidal block pre-
viously employed for five months. It was, therefore,
removed, and the new ventro-inguinal block applied.
The ring had contracted very considerably under the
previous treatment, if the testimony of the patient him-
self be deemed conclusive, but it still received two fin-
gers with facility, and the bowel had protruded occa-
sionally, notwithstanding the presence of the instru-
ment, up to the 24th of December, 1835, about which
time the new ventro-inguinal block of Dr. CHASE was
employed. The retention continued perfect from that
time until the Committee lost sight of the patient in
August, 1836.
July 11, 1836. The patient, examined by the Chair-
man, states that he has had no return of colic since
the new block was employed. The ring was found a
little larger and less resisting than that on the oppo-
site side, the edges somewhat thickened but softer than
the original structure. Though ordered to wear his
truss at all times, he repeatedly relinquished it during
the month of June, and passed from his chamber to
the yard, ascending and descending the stairs without
it. Once, at night, when he had laid aside the instru-
ment on retiring, he rose, and ran to a fire, at a con-

APPENDIX.
105
siderable distance, not discovering the omission until
his return. Not the slightest sign of protrusion took
place during these exertions. The age and profession
of this patient, coupled with the extent of the orifice,
was thought a sufficient reason for avoiding any in-
tentional tests of the radical cure of the hernia in this
case, and the patient was enjoined to continue the use
of the truss during life, notwithstanding the progress
of the case had so far transcended any anticipation en-
tertained by the Committee at the time of the Prelimi-
nary Report.
The patient was seen by members of the Committee
several times after the 11th of July. This truss gave
no inconvenience, and he stated that he was generally
unconscious of its presence. He had renewed his
labours as a ship watchman, and frequently assisted in
unloading vessels.
Jan. 12, 1837. This patient has gone to sea as a
sailor, and the Committee have lost sight of him.
There were some circumstances of peculiar interest
in this case. On the 11th of July, 1836, the spermatic
cord on the affected side was found enlarged to at least
three times its natural size. It was soft, and did not
feel as if the veins were varicose. The correspond-
ing testicle was much reduced in size, and felt like a
mass of œdematous cellular tissue enclosed in a firmer,
but ill-defined cyst. The sac still continued very thick,
but had contracted to about one-third of its former
dimensions. The parts were critically examined by
13

106
APPENDIX.
Drs. HORNER and HAYS, and by the Chairman of the
Committee. Some doubt existed as to the complete
adhesion of the neck of the sac; one of the gentlemen
mentioned being convinced of its occlusion; another
being of opinion that it remained pervious, and the
third declining to decide the question.
fea
Dr. R. COATES was inclined to attribute the enlarge-
ment of the cord to an interstitial deposit of the con-
sistence of jelly, and the alteration of the testicle to
absorption from an embarrassment of circulation for
many years, occasioned by the continued pressure of
the protruded intestines and ill-adapted trusses.-Final
Report.*
Common Inguinal Hernia from a fall; seven years stand-
ing; age of patient 13 years.
Radical cure in six
months, under the use of Chase's Common Inguinal
Truss.
CASE II. By the Committee. Oct. 5, 1835.-Master
S-, a fine healthy lad, 13 years
years of age, has laboured
under inguinal hernia of the right side for about seven
years. The tumour has never been of very large size,
and is thought to have been first caused by a fall.
10
This lad had used Mr. CHASE's truss for about two
weeks, never having previously employed any other
*This patient has two sons, both of whom have had inguinal
hernia, one of the right and the other of the left side. One of them
is cured of his rupture; the other is still under treatment.
er
H. C.

APPENDIX.
107
instrument. The case was examined a few days ago
by Drs. HORNER, HAYS and BRYANT, when the truss
was removed, and the patient was permitted to cough,
without experiencing any descent of the bowel. The
hernia has not been down since the first application
of the truss.
The Committee requested Mr. CHASE to remove the
truss, which he did. The parts beneath the pad, and
for some distance above it, were evidently in a state
of considerable irritation. Some scattered ecchymoses
were visible, and slight contusion was obvious over
several square inches of surface. The temperature of
the skin was but little exalted, the swelling was very
slight, there was no complaint of pain or pressure, and
no febrile reaction. The boy says that the instrument
has never given him much pain, but now and then
some uncomfortableness, which has induced him to
slacken the perineal strap occasionally, so as to alter
the bearing of the block; hence the great extent of the
irritation. The action of the block has not extended
to the external ring, into which the tip of the little fin-
ger could be introduced, by reverting a portion of the
skin of the scrotum; but the upper two-thirds of the
abdominal canal, and the parts around the internal
ring are completely involved in the marks of irritation.
corrente
The Committee did not think it right to subject the
patient again to the danger of coughing, so early in
the progress of the treatment, and the case is therefore
left sub-judice.

108
APPENDIX.
Oct. 13.-This boy appeared before the Committee;
truss removed; the ecchymoses have become less ap-
parent; the redness continues; there is a depression of
the integuments where the block rests, obviously re-
sulting from some lasting compression in the subcuta-
neous cellular tissue. Truss re-applied.
orff to
Dec. 5.-This case has been constantly under the
eye of the Committee from the last date, and the her-
nia has never descended. Leaving off the truss with
impunity for short periods of time, while running about,
he still re-applied it, by the special request of his father,
when wandering long distances into the country. At
the date of the last note, Nov. 24, there was no ap-
pearance of tumour; there was slight blueness of the
integuments on the affected side, but no other differ-
ence between the two sides was observable.
*onsidst rolmopa
Your Committee have the most favourable anticipa-
tions in this case.-Prel. Rep.
folio Jon
This case is narrated to Dec. 5, 1835, in the Pre-
liminary Report, (Case II. p. 315.)
102
April 2, 1836. Examined by the Chairman. The
external rings on both sides offer the same resistance
to the finger, and appear to resemble each other ex-
actly. The patient feels no sensation of weakness or
other symptom of the existence of hernia. He has
seldom had recourse to his truss since the 5th of
December, 1835; having only employed it when re-
sorting to unusual exertions. Pronounced cured and

APPENDIX.
109
ordered to lay aside the instrument entirely. The de-
pression of the integuments beneath the block has en-
tirely disappeared, as has also the redness. Bisvig
fonodga & odi
552
Jan. 11, 1837. The lad continues perfectly well.
Has not worn his truss since the last date. He is
radically cured.-Final Rep.
de molder by ne
Common Inguinal Hernia; four months standing; age
of the patient about 30 years; congenital enlargement
of the lower part of the abdomen; both external abdomi-
nal rings preternaturally large and weak; ring on the
affected side rendered smaller and firmer by the treat-
Radical cure in thirteen months.
ment.
CASE III. By the Committee. Oct. 7, 1835.-J-
B-, a gentleman well known to many of the members,
aged about thirty years, in good general health, has
been subject to regular inguinal hernia on the right
side for about four months. He cannot account for
the accident. Soon after the appearance of the tu-
mour, he requested the opinion of Dr. HORNER, who
pronounced upon the character of the disease, and re-
commended him to the care of Mr. CHASE. The truss,
with Hood's common inguinal block, in default of Mr.
CHASE's, was first applied on the 22nd of June, and
Mr. CHASE's block was substituted as soon as prepared,
about two weeks after the commencement of the ex-
pulsion of the bowel.
oft
barst
Banos
100 botesibat bider Hauld
The truss was removed to facilitate the examination.
The lower part of the abdomen was rather unusually

110
APPENDIX.
prominent, particularly in the space midway between
the superior anterior spine of the ilium and the sym-
physis pubis, on each side, where it swelled obviously
outward, like a spherical tumour. This prominence
was not produced by adipose matter, or by any other
deposit in the subcutaneous cellular tissue, but was
plainly the result of a slight enlargement of the abdo-
minal cavity in this region. The skin above the brim
of the pelvis was easily depressed into the external
ring, by the finger, so that it was altogether unneces-
sary to revert the skin of the scrotum, in order to fa-
cilitate the examination of this outlet.
The external abdominal rings were unusually large.
The point of the index finger entered them readily, and
to such an extent that it could be made to engage itself
beneath the outer edges of the rings, which were thicker
and more abruptly defined than usual. The rings were
not only broader, but much longer than common; pro-
bably from a deficiency of the transverse fibres which
should strengthen the connexion of the two columns
of the tendon of the external oblique muscle, at the
summit of each ring. It is obvious, from these remarks,
that the patient had a predisposition to inguinal hernia,
probably from his birth.
ert so badloge Jant as
8410
The external ring on the right side had not been in
any degree affected by the pressure of the truss, but
the parts covered by the block presented an erythema-
tous blush, which indicated considerable irritation.
This irritation extended over nearly the whole length
of the abdominal canal, and to a considerable distance

APPENDIX.
111
around and above the site of the internal ring. The
patient did not complain of any notable inconvenience
from the pressure of the block.
The index finger was placed above the external ring,
and the patient was caused to make strong and re-
peated efforts to cough. This caused a sensation of
a strong impulsion directly outward from the abdomen,
to be felt by the finger; but no tendency to dilatation
was observed in the abdominal canal. Precisely the
same results followed the experiment when essayed in
the same manner on the sound side.
en good and a
and Jaxud edt tuo
of It is somewhat difficult to account for the security
of the bowels in the present state of the case. It is
true that the course of the spermatic cord through the
canal, is rather more distinctly traceable on the right
side than on the left, and the tendinous covering of the
canal on the same side feels somewhat harder to the
touch; but there is no appreciable thickening of this
part, nor is there, as yet, the slightest condensation of
the skin or subcutaneous cellular tissue. The former,
indeed, glides over the surface of the fascia beneath,
with rather unusual facility.
Oct. 24.-The patient is still under treatment, but
has made several efforts while the truss was removed,
without any protrusion of the bowel, and this accident
has never occurred since the first application of the
truss.-Prel. Rep.
Diet exeor
arsen bas awob at sinned od sed
sand bool ogul sedier qui
medy gonemey
tode gailion

112
APPENDIX.
This case is drawn up to Oct. 24, 1835, in the Pre-
liminary Report, (Case III. p. 315.)
sbold
Feb. 1837. (Day of the month not noted.) The pa-
tient omitted the application of the truss, occasionally,
from May to July, 1835, and even worked in the har-
vest field without it. In July he was advised to relin-
quish it entirely, being pronounced cured. He has not
steadily complied with this wish. The external ring
on the side affected is now decidedly smaller and more
resisting than that on the other side. Its edges are
thickened. Ample testing, by vigorous exercise with-
out the truss, has been resorted to. The patient was
strongly pressed to relinquish the truss entirely, by the
Chairman of the Committee. He is believed to be
radically cured, but liable to hernia on the opposite
side of the abdomen from slighter causes than usual,
owing to the original structure of the abdomen.-Final
Rep.
Inge
Common Inguinal Hernia, from Pertussis; accident of
seven years standing; age of patient 9 years; treated
by Stagner's or Hood's block for some months, then by
Chase's Inguinal Truss; retention by the latter perfect
after three days. Radical cure.
robon lite ei in
Hag ofT
CASE IV. By the Committee.-A rude boy, aged
about 9 years, labours under inguinal hernia on the
left side, which was caused by pertussis when he was
two years old. The boy suffers very little incon-
venience when the hernia is down, and seems to care
nothing about it. Ring rather large. Hood's truss,

APPENDIX.
113
with a block now in our possession, was applied by
him, March 31, 1835. It was worn constantly for two
months; then occasionally, until the present time.
During this period of time, the bowel has descended
occasionally, but has been reduced by the patient or
the operator, with the utmost facility.
Oct. 10th.-Yesterday the patient was produced
before Dr. Ashmead, who found a portion of intestine
in the sac.
The block of Mr. CHASE, i. e. the com-
mon inguinal block, will be applied to day, for the first
time. The patient had worn other trusses, none of
which prevented the descent.
Oct. 13th.-The Committee examined C- this day.
The truss had not prevented the descent. The bowel
was returned by Mr. Chase, and the truss re-applied.
The boy is extremely careless, and was not himself
aware of the descent. He had been exercising him-
self violently in trundling a hoop, and had neglected
an appointment made for the purpose of having his
truss properly adjusted.
Dec. 5th.-This patient has been frequently before
the Committee, and the retention of the bowel, since the
last date, has been perfect. Considerable irritation of
the parts beneath the block is still subsisting, and slight
efforts, without the truss, do not produce protrusion.
The case looks very favourable when the habits of the
boy are taken into account. He still wears his truss.
-Prel. Rep.
14

114
APPENDIX.
March 29th, 1837.-This case is detailed to Dec. 5,
in the Preliminary Report, (Case IV. p. 316.) The
patient has been repeatedly before members of the
Committee, since the last date, but nothing peculiarly
worthy of comment has been observed except what is
contained in the following note of his father, which
communicates the result. He is believed to be radi-
cally cured.
Philadelphia, January 14, 1837.
GENTLEMEN:
I wish to inform you that my son I believe to be
quite well of his rupture. He is now gone to to
a boarding-school, and before he left, I examined him
carefully, as I have been in the habit of doing while he
was under the care of Dr. CHASE. His bowel has
never been down, to the best of my knowledge, since
the first application of the instrument. He has never
complained of pain in the part. He did not take his
truss with him, as I did not think it necessary. I do
not know the time that he laid aside the truss, but I
think it might be in April last.
—
H——————C—_—_—_—_.
Drs. COATES, PARRISH and ASHMEAD.*
* Previous to the first application of the truss, Dr. MUTTER re-
quested that he might witness the case, with its treatment and
result. Accordingly, he saw him several times during the treat-
ment; and examined him this day, (May 30, 1836.) He pro-
nounced the case "successful." The two sides have nearly a similar
appearance, but Dr. MUTTER was of opinion that the parts on the side

APPENDIX.
115
Common Inguinal Hernia, of one month's standing, from
running violently; age of patient about 35 years. Ra-
dical cure in five months.
This case is detailed up to Dec. 5, 1835, in the Pre-
liminary Report, (Case V. p. 317.)
a
9
CASE V. By the Committee. Oct. 1835.-Mr.
gentleman of high respectability, well known to one of
the members of the Committee, was examined by the
Committee on this day. Age about 35 years.
The patient suddenly became subject to hernia, in
running after an omnibus, between three and four
months ago. He has worn CHASE's truss, with the
common inguinal block, for about three months unin-
terruptedly. The bowel has never descended since
that time.
Condition of the parts.-There is a well-defined red-
ness of the integuments, at the part covered by the
block, but there is no trace of condensation in the sub-
cutaneous cellular tissue. The external ring on the
affected side seems to be a very little contracted and
firmer, for which fact it is difficult to account, as the
block does not act at this point. It may possibly re-
sult from a congenital peculiarity. The sliding of the
skin over the abdominal canal, is not restricted.
where the hernia had existed, were a little thickened. The patient
had some enlargement of the spermatic cord, which might, in part,
account for this thickening. It still continues, and was sufficiently
obvious when the truss was first applied.

116
APPENDIX.
Tests of radical cure. The patient was examined by
Dr. Hartshorne, a few days ago. His truss was re-
moved, and he was requested to cough, which he did,
as he states, repeatedly and violently, while the Doctor
made every necessary examination of the parts. Dr.
H. then stated, that "he saw no marks of any thing
wrong about the case." Slight efforts to cough were
made before the Committee. There was evident pro-
pulsion of the integuments immediately over the in-
ternal ring, but they were not appreciably greater on
the diseased than on the sound side.
-
The probabilities of radical cure, in this case, are
very strong; but the Committee, not wishing to hasten
Mr. CHASE, in subjecting the case to any farther test,
by their advice, simply requested to see the patient oc-
casionally, after the final removal of the truss. Truss
continued.
December 5.-There has never been any return of
the protrusion since the last date. The patient has
attended to his business, without a truss, for some
weeks past. The probability of radical cure in this
case is very strong.-Prel. Rep.
Feb. 1837. (Day of the month not noted.) This
patient states that soon after the last note of the Com-
mittee, he was alarmed by the appearance of what he
mistook for the return of hernia, but on applying to
Dr. CHASE, he was convinced of his mistake. The
latter gentleman in his treatise already quoted, men-
tions that sometime after the 5th of Dec. 1835, he

APPENDIX.
117
consulted him several times under this impression.-
(p. 148.) He is decidedly a hypochondriac. At his
own instance, the truss was re-applied though deemed
unnecessary. Sometime afterwards his surgeon re-
presents, that he had an accumulation of serum in the
sac; a circumstance which, as Dr. CHASE justly re-
marks, is not uncommon during the treatment of her-
nia, even when accurately retained, and which need
not occasion alarm. This serum retired into the ab-
domen on pressure, proving that the neck of the sac
was not, at that time, obliterated.
---
No signs of the sac are now traceable, and no re-
mains of the effusion have been visible for a long time.
There appears no reason to believe that the latter had
an abdominal origin.
The patient occasionally relinquishes the truss for a
time, but labours under nervous timidity with regard
to a relapse. The Chairman of the Committee, by
whom the last examination was made, strongly urged
the entire abandonment of the instrument, on the plea
that the unnatural and unnecessary support might
eventually produce weakness by removing the neces-
sity of the functional exercise of the part; but it is not
probable that the patient will permanently adhere to
the advice, as the truss gives him no inconvenience.
He is believed to be radically cured.
The apparent anomaly of the preternatural diminu-
tion and firmness of the ring, noticed in the Prelimi-
nary Report, which could not be explained at that time,

118
APPENDIX.
has been proved to fall within the range of a general
law, by the subsequent observations of the Committee.
It is now still more remarkable than when first noticed.
Common Inguinal Hernia, of many years standing; age
of the patient supposed to be about 35 years; cause un-
known; imperfect retention by the best English trusses;
also by Stagner's or Hood's block; perfect retention by
Chase's Inguinal Truss.
CASE VI. By the Committee.-Mr. P-, a highly
intelligent and athletic English gentleman, has laboured
under inguinal hernia on the left side, for a number of
years. The cause of the accident is unknown to the
Committee. He had worn a variety of the most lauded
trusses before applying to Dr. Hood. No truss had
ever retained the hernia effectively. He applied Dr.
Hood's truss under his direction, and continued it for
more than four months. This truss produced great
pain, probably from pressure on the brim of the pelvis,
and it did not effectually prevent the descent of the
bowel.
Oct. 13th, 1835.-Examined by the Committee. This
patient is a remarkable example of muscular power,
and his abdominal muscles are exceedingly strong.
The abdomen is of an unusually round form, and there
is a thick layer of adeps over the lower part of the
abdomen, which is only partially absorbed under the
pressure of the pad, although considerable irritation
has been produced.

APPENDIX.
119
The external abdominal ring cannot be distinctly
felt, in consequence of the amount of adipose matter
in the subcutaneous cellular tissue. This is a very un-
favourable case for the action of trusses; yet, although
no instrument previously employed had been able to
retain the bowel under ordinary exertions, the patient
has had no protrusion since the first application of Mr.
CHASE's truss, which has been steadily worn since May
20, 1835, and he has led, for a considerable part of
this time, the life of a hunter, leaping fences, riding
desperately, and following the favourite pursuits of an
athlete. He is enchanted with the instrument, and
protests that he is generally insensible of its pressure.
Dec. 5th.-This patient has not appeared again be-
fore the Committee, probably because much of his time
is occupied in field sports.-Prel. Rep.
The Committee lost sight of this case soon after the
last date in the Preliminary Report, (p. 317.) The
tests of the retentive power of the instrument were
violent, but the question of radical cure could not be
solved, as the gentleman left Philadelphia while under
treatment. Dr. CHASE states that when last seen by
him, in March, 1836, the patient was not wearing the
truss and had not experienced any protrusion.*
* When seen in March last, this patient was not wearing his
truss. No return of the hernia took place, and soon afterwards he
left the city for New Orleans, without applying for further advice.
He is now in that city, and is believed to be radically cured.
H. C.

120
APPENDIX.
Ventro-Inguinal Hernia, of several years standing; age
of patient 33 years; relief, and prospect of cure from
Chase's Common Inguinal Truss.
CASE VII. By Dr. I. Parrish. Ventro-Inguinal
Hernia.
-, aged about 33 years, a sugar-
refiner, accustomed to lifting heavy weights, has had
a rupture for seven years. The first descent occurred
in the act of lifting a heavy barrel. When he ascer-
tained the nature of the injury, he bought a truss of a
druggist, which he wore for about a year; this suc-
ceeded in retaining the parts, and on removing it, he
found no protrusion took place. At the end of a year,
thinking that he was cured, he threw aside the instru-
ment, and continued his laborious occupation without
it. In about two months, while lifting a heavy weight,
he had another descent. He had recourse to trusses
again, but never could procure one which he liked as
well as the first. He frequently experienced difficulty
in keeping up the bowel. The hernia continued in this
situation until May 13, 1835, when he applied CHASE'S
truss.
At this time the surgeon thought that the rings were
unusually large, and near to each other. The health
of the patient was much impaired; he had nausea and
eructations, particularly after eating; constipation of
the bowels; general debility, &c.
He states that he experienced considerable pain and
soreness for some time after the first application of
the instrument. This subsided, and lately the truss

APPENDIX.
121
has been very easy. He has been in the practice of
removing it at bed time, for some weeks.
1st Mo. 24th. Saw him in the evening; he had re-
moved the instrument about two hours before, and
had walked some squares; he has removed it for a few
hours once before, without a descent. There has been
no appearance of the tumour. There has been a slight
increase in the natural hardness of the parts about the
rings. The passage of the finger through the abdo-
minal rings appears to be obstructed.
He states that his general health has been much
improved since applying the instrument.-Prel. Rep.
berielomnos
Justing
eliitl
This patient is the subject of the seventh case of
the Preliminary Report. He has disappeared, and the
Committee know nothing of his history after January
24th, 1836. His condition then gave promise of cure.
The case has not been seen since the invention of the
Ventro-Inguinal Truss.-Final Rep.
CASE VIII. Of the Preliminary Report; Femoral
Hernia, from notes by Mr. Chase, examined and approved
by Dr. B. H. Coates.-Oct. 13th. I visited this day,
in company with Dr. B. H. Coates, Miss M. S., aged
about 28 years, and found her labouring under a
femoral hernia on the left side. The protrusion was
dounds
* This patient has not presented himself for further advice.
H. C.
15

122
APPENDIX.
about as large as a walnut. Cause unknown. The
accident occurred about two years ago. The patient
has suffered several times from obstruction of the
bowel; she has been obliged to confine herself repeat-
edly to her bed, and has suffered much pain and great
inconvenience from the disease.
15th.-On examination, we found the protrusion of
the bowel greater than it was on the 13th. By steady
taxis, the bowel was reduced in four or five minutes,
and the truss with the femoral block was applied in the
presence of Dr. COATES.
16th.-Visited the patient with Dr. C. We found
the patient comfortable; she complained of a little
soreness.
19th.-Up to this period, the patient has laid her
truss aside at night. She found the tumour slightly
apparent. It was much smaller in the morning, nor
did it give her pain on its appearance, as it had done
previous to the application of the truss. Directed
her to wear the instrument day and night.
21st. We again visited the patient, and found her
attending to domestic affairs. The bowel had not ap-
peared since the last visit.
red
26th. The patient has attended church. She walked
much on Monday and to-day. She complained of
soreness beneath the block.

APPENDIX.
123
30th. The bowel has not passed down; the soreness
has in a great measure subsided.
Nov. 10th. The truss is now worn with ease.
30th. The truss is still worn with ease. It is thrown
off at night.-Prel. Rep.
This patient is said to have had no return of the
protrusion, but she is represented as still using the
truss. The Committee have had no opportunity of
examining this case at any time, and are not acquaint-
ed with its history since November 30, 1835.*-Final
Rep.
Joatst
CASE IX. of the Preliminary Report; Congenital Her-
nia. By Dr. Ashmead.-Master Ruth, aged 6 years,
with a robust constitution, has congenital inguinal her-
nia of the right side. It is large, and passes into the
scrotum. The external ring on both sides large and
relaxed. The patient having tried two or three different
forms of trusses, directed by physicians, and these fail-
ing to retain the bowel, for a single day, and having
suffered severely from them, the mother then despairing
of a cure or relief, permitted the lad to go without any
support of the parts: but the boy having suffered symp-
toms of strangulation several times, I was called to see
* This patient still continues the instrument by my advice. The
hernia had given her unusual trouble; she is past the meridian of life.
She has removed the truss twice in my presence without a protru-
sion of the bowel, but as it is worn with ease, giving her great
comfort and safety, I have recommended its continuance.-H. C.

124
APPENDIX.
him, and directed Mr. CHASE's truss to be applied. At
the time the bowel was readily restored, but, on re-
moving the thumb from the ring, while the patient was
in the erect position, without any effort being made, it
immediately fell down to as great an extent as before.
The truss was applied by Mr. CHASE 16th of October,
1835, and it has completely and uniformly retained the
bowel within the abdomen, so that it has not once since
descended; and now, December 4th, the bowel does not
descend, even when the truss is removed, and the pa-
tient stands erect and still; though so short a time has
elapsed since its adjustment. I thought it wrong to
make him cough or exert his abdominal muscles, to
show how far it would be retained. The sac is thick-
ened and remains down. Slight inconvenience was at
first felt from the pressure of the block, though the
spring is not stronger than those in general use; (per-
haps not so strong.) It produced inflammation of the
skin beneath it, which was moderated by several folds
of linen under the pad. Now no inconvenience is felt,
and it has ceased to irritate the parts. In this case
the block is placed over the external ring and lower
half of the abdominal canal. No evidences of thick-
ening of tissues or adherence of parts about the exter-
nal rings as yet exist. The case is still under treat-
ment and observation; and its future result will be
communicated when sufficient time has elapsed to
judge of its final success.*-Prel. Rep.
* March 17th, 1836.-I examined this case in the presence of
the young lad's mother, who informed me that she had, on two for-
mer occasions, removed the instrument for short periods. The
truss was again removed; the parts about the rupture appeared

APPENDIX.
125
This case has not been heard from since December
4th, 1835.-Final Rep.
Femoral Hernia, of two years' duration; age of patient 30
years; Hood's Femoral Block not permanently toler-
ated; other trusses producing imperfect retention; ap-
parently perfect retention by Chase's Femoral Truss,
with the Ovoidal Block; perfect retention by the new
Femoral Truss; radical cure.
CASE X. By Dr. Ashmead.-Aged about 30 years;
good constitution, sedentary habits, occasionally uses
violent exercise, small femoral hernia of the left side
for two years.
For this affection the patient has tried a variety of
trusses, with strong springs and soft large pads, all of
which failed in retaining the protruded intestine; so
that he despaired of ever being cured. In June last,
Mr. CHASE applied his truss, which retained the bowel
constantly and perfectly, and gave much less pain than
the others had done. He says he suffered very little
inconvenience from it; indeed it now sits so easily,
that he hardly knows when it is on. It is now three
more thickened than usual. I applied a second truss, which co-
vered the site of the internal ring more accurately than the first had
done.
July 24th.-Examined the case; no alteration in the appearance
of the parts; patient has left off his truss occasionally.
August 1st, 1837.-I have not seen this patient since July 24th,
1836, he having never called on me, and I have been unable to trace
him in the city.
H. C.

126
APPENDIX.
months since its first application; he only wears it
when using violent exercise, as in gunning. Last week,
while gunning, he forgot to apply it, he jumped over
fences fearlessly, without any descent being produced.
Coughing appears to give to the finger placed over the
hernial orifice a very slight impulse. The skin over
this spot bears marks of pressure. It is discoloured,
hard, and drawn backward, and slightly upward, as if
the soft parts beneath had been absorbed, or as if they
were adhering closely to the parts beneath; and this
appearance presents a striking contrast to the corres-
ponding parts on the opposite side.-Prel. Rep.
This patient is the subject of a note by Dr. ASH-
MEAD in the Preliminary Report, q. v. (Case X. p.
319.)
March 29th, 1837.-The truss has been occasionally
worn, in this case, up to the present time, but only for
a few hours at a time, during unusual exertions. The
new femoral block of CHASE was substituted for the
ovoidal block soon after the invention of the former.
This occasional use has prevented the return of the
subcutaneous depositions; and the patient states that
the block "embeds itself so that the shoulder, or pro-
jection, dips underneath a sharp edge of something
which I suppose is Poupart's ligament, and, whenever
it is applied, rises up under it." This is his own phrase.
The depressed skin now plays freely over the parts
beneath, so that no adhesion exists between the in-
teguments and the hernial orifice. The Committee
have enjoyed no recent opportunity of witnessing the

APPENDIX.
127
position of the truss. Neither the old nor the new
Femoral Trusses have given any material incon-
venience.
The patient assures us that the action of Hood's
Femoral Block, which had been previously employed,
though when in its intended position it apparently re-
tained the hernia, "could not be borne for any length
of time, and that, as soon as it was moved, the bowel
descended." It produced great inflammation, and a
sore over Poupart's ligament, which confined him for
two weeks to his bed. The orifice in this case must
have been large when the treatment by wooden blocks
commenced, as the bowel then slipped down and was
returned by the fingers with the utmost facility. The
descent always took place on walking across the floor
of a room.
Since the time of the Preliminary Report, he has
tested the cure by pursuing his usual avocations,
swimming and other severe exercises, for weeks to-
gether, without any application of the truss. His oc-
casional use of the instrument is made entirely at his
own suggestion. He is considered radically cured;
but, whether the result has been obtained solely by the
old, or partly by the new Femoral Truss of Dr. CHASE,
the Committee will not attempt to determine. Refer-
ence to the Preliminary Report will show that the cure
was far advanced while the ovoidal block was in use.
The Committee place much confidence in the
repre-

128
APPENDIX.
sentations of the patient himself in this case, as he is
a gentleman of education and intelligence.-Final Rep.
Large Ventro-Inguinal Hernia, of many years' standing;
producing ill health and disability; age of patient 60
years; complete relief and perfect retention by Chase's
Ventro-Inguinal Truss.
CASE XI.-Note I.-By the Committee.-Major W.
a gentleman of about 60 years of age, has had for many
years a large, direct or ventro-inguinal hernia, with an
orifice of very considerable size. The hernia has given
great distress, disabling him from business, and some-
times confining him to his bed. The patient, before
applying to Mr. CHASE, had worn a variety of trusses
"with little or no benefit," to use his own language.
"For upwards of twelve weeks past, it (the hernia,)
has been uniformly retained by Mr. CHASE's inguinal
pad." He can now walk the room with the truss off,
and without producing any appearance of the hernia;
which could have been scarcely possible, even by ac-
cident, before the application of this block. With the
instrument applied, he is able to "walk a considerable
distance with comparative ease and firmness." Neither
the patient nor his surgeon have relinquished their
hope of a radical cure in this very unpromising case,
and the Committee are unwilling at present, to express
any opinion on the probability of such an event.-Prel.
Rep.
This is the case marked Note I., in the Prelimi-
nary Report. The estimable and companionable old

APPENDIX.
129
gentleman who is the subject of it, has been seen
several times by the Committee during the year 1836.
He has been restored from a condition which render-
ed life almost a burden, to one of high comfort and
enjoyment. The Preliminary Report displays the
effect of the ovoidal block in securing the permanent,
but probably, not the accurate, retention of the bowel,
for he could only venture upon very moderate exercise
with safety, and continued liable to much abdominal
uneasiness at times, until the ventro-inguinal block was
brought to perfection, and substituted for the previously
applied and worse adapted one. Since that time he
has been restored to perfect health, walks long distan-
ces without suffering, has passed a season in his fa-
vourite amusement of trout fishing among the moun-
tains, and wears his truss with scarce a perception of
its presence. During occasional relinquishment of the
instrument, which has now and then continued for
some hours, no signs of protrusion have occurred. No
accurate examination of the ring has been made for a
long time. It is deemed altogether improper to test,
in this case, the natural powers of retention, and the
instrument will be worn during life.-Final Rep.
tom
quodue out to
Besides the cases just detailed, your Committee, or
particular members of it, have been presented with
several others, at different times, which were illustra-
tive of particular points of interest with regard to the
action of the several blocks, but which did not appear
to require a regular report during the present session.
Some of them are made the subject of the following
notes.-Prel. Rep.
16

130
APPENDIX.
Common Inguinal Hernia; Stagner's or Hood's Block
employed; deep linear depression of the integuments;
absorption of a portion of the tendon of the external
oblique muscle; perfect retention by Chase's Ventro-
Inguinal Truss; improved condition of tendon; case
still pending.
at Zoold Isbio
Joure
o od ton videdorg tod
CASE XII.-Note IV.-A man of middle age, with
inguinal hernia, was examined by the Chairman, about
the end of October last. He had one of Hood's original
blocks in action at the time, and stated that he had
worn it for a considerable period. The direction of the
shoulder of the block was nearly perpendicular, and, in
the opinion of the examiner, it was too near the mesial
line of the body to act upon the upper end of the in-
guinal canal. It is not recollected by whom the in-
strument was applied, but according to the statement
of the patient, it had always retained the bowel. It
should be borne in mind, however, that it is difficult to
detect a small protrusion of intestine, confined to the
upper end of the canal. The truss was removed by
Mr. CHASE's order, the patient being then about placing
himself under his care; and so great was the absorption
of the subcutaneous matter, and the integuments, that
the skin was brought into apparent contact with the
tendons beneath, and it is the opinion of the examiner
that, had the pressure been injudiciously continued, the
integrity of the tendons themselves would have been
threatened. The depression thus occasioned was great-
est at the prominent extremity of the shoulder of the
block, and continued-gradually becoming less marked
--for about two-thirds of its length upwards. The

APPENDIX.
131
depression was very narrow, and the parts about the
most prominent line of the block were alone imbedded
in it. Around the edges of the block there was some
swelling, apparently produced by a deposit of some
kind in the subcutaneous cellular tissue. The patient
has not since been seen. This note is drawn out from
memory. Prel. Rep. gra pelang
Ismetrs.edi
erdug
ogbo on
The commencement of the history of this case will
be found in Note IV. of the Preliminary Report, (p.
321,) and was written in December, 1835.
Sanga orb
or to Frag
March 5th, 1837.-The patient was examined by the
Chairman of the Committee this day. Dr. CHASE states
that the patient continued to wear the truss with Stag-
ner's or Hood's Inguinal Block, for three or four weeks
after the examination in October, 1835, in consequence
of neglecting to call on his surgeon agreeably to ap-
pointment. This unfortunately led to a more rapid
alteration of the part of the tendon pressed upon than
was calculated on, either by the Committee or his sur-
geon. The new Ventro-inguinal truss was applied as
soon as completed. The present condition of the parts
about the orifice is as follows:as nobno oth
nodt to levomer off
The integuments are still considerably depressed in
consequence of the subcutaneous absorption, but the
block applies itself equally over a wide space, without
bearing too forcibly on the tendons. The retention
has been perfect from the first. The skin is not ren-
dered preternaturally thin. It is slightly red from the
debility of the capillaries produced by pressure, but

132
APPENDIX.
there are no signs of irritation about the part. The
skin slides over the parts beneath, with the greatest
facility, proving the absence of adhesions.
The usual resistance to the finger offered by the ab-
dominal parietes is wanting over a space of about two
fingers breadth, running perpendicularly upward from
the edge of the os pubis at the site of the external
abdominal ring. The existence of the tendon of the
external oblique muscle is obscure throughout this
space, and is not perceptible at all toward the lower
part of the space. On reverting the skin of the scro-
tum before the finger, into the external ring, the inter-
nal column is found well defined; the external column
is indistinct. The tendon can be felt in a healthy con-
dition far to the right, but appears gradually reduced
to mere cellular membrane as it approximates to the
ring, the upper margin of which cannot be determined
by the sense of touch. The spermatic cord is felt
throughout nearly the whole length of the abdominal
canal, with such extreme distinctness that it might be
supposed to be covered only by a thin layer of free
cellular membrane. Dr. CHASE thinks that the absorp-
tion of the tendon was considerably more extensive
than at present, at the time of the removal of the in-
strument formerly in use, and that the restitution of
the natural structure is now making slow progress.
On this point the Committee have no knowledge from
personal observation.*-Final Rep.
frog good and
*This gentleman continues to wear my Ventro-inguinal truss;
the tendon is gradually improving, and will, I think, eventually

APPENDIX.
133
CASE XIII.-Note V.-A patient, with inguinal her-
nia, was recently presented before the Chairman. He
stated that he had worn a truss with one of the wooden
blocks, until it had produced a degree of absorption de-
scribed as equal in extent to that mentioned in the pre-
ceding note. He had then slackened the instrument, and
finally relinquished its use for some time. At the time
of the examination, the parts which had been com-
pressed, had resumed their usual level and aspect. The
adipose matter had been re-deposited in the subcuta-
neous cellular tissue, and no obvious induration about
the canal or the rings could be detected.no i halles
of vitanos of
This note is introduced to show that adhesions or
mes
regain its normal firmness. The instrument is worn with ease,
giving perfect security against any protrusion of the bowel. Under
these circumstances I shall recommend that the instrument be worn
for some years, perhaps during life. He is a muscular, powerful
man.
The above case fully illustrates the danger which must inevitably
follow the employment of instruments armed with Mr. Stagner's
and Dr. Hood's blocks. I have met with several patients wearing
the above-mentioned blocks, some of whom, aware of their situation,
have visited this city from the South and West, in order to obtain
relief. The instruments taken from these patients, some of which
were applied by the inventors themselves, are now in my possession.
I have also other instruments of the first class, Price's, Semple's,
etc., which I removed from patients labouring under hernia, ac-
companied by a partial destruction of the tendons, from the action
of those instruments. Semple's truss (so called) consists merely
of a leaden conoidic block attached to the late Dr. Hull's spring.
This instrument is capable of doing great injury to the parts on
which it presses, in a very short space of time.
of time. eod
H. C.

134
APPENDIX.
indurations are not the invariable result of the action
of solid pads. The Committe have seen, as yet, no con-
clusive evidence that they are ever so produced. This
note is also drawn up from memory.—Prel. Rep. Bold
zo ni len
Sedizon
This case has not been again presented to the Com-
mittee. The patient was thought to be radically cured
when the note was written.-Final Rep.
odt 25
bonolis
109
bas loyal
bed borong
Note VI. of the Preliminary Report, (p. 321.)-With-
in a few days, the Chairman of the Committee was
called in consultation with a medical gentleman from
the country, to see a lady labouring under a small her-
nia, believed to be femoral, but its precise character
could not be positively determined, owing to the sex
and embonpoint of the subject. The edge of Poupart's
ligament could not be distinctly felt, and the case may
possibly prove one of direct ventro-inguinal hernia.
When reduced, the rupture always returned, if the
patient rose from her couch. CHASE's truss, with a
small femoral block, was applied by the Chairman of
the Committee, and during various efforts to test the
security of the parts, the retention appeared perfect.
It is very improbable that any soft pad of similar di-
mensions could have produced such security. The
patient left the city almost immediately, and her phy-
sician has not made any further communication on the
subject.-Prel. Rep.
The patient mentioned in Note II. (p. 320,) of that
paper, has been much deranged, and his insanity has

APPENDIX.
135
interfered with the treatment. He is no longer under
the observation of the Committee.-Final Rep. aston
NOTE II.-From notes by Dr. Gerhard, and the Com-
mittee. Mr. P, at the Pennsylvania Hospital, who
had worn Hood's truss with an inguinal block for some
time, and who is said to have been considered radically
cured by Drs. HOOD and BODDER, had a recurrence of
the rupture after the close of their treatment. In Oc-
tober last, while using Mr. CHASE's truss, after the re-
lapse, he was presented before the Committee by this
gentleman, to rebut the charge that his blocks were in-
capable of producing sufficient irritation to secure ad-
hesion in the parts beneath; and also to show that the
most severe inflammation which could be produced by
the instrument without gross mismanagement, was not
productive of danger to the peritoneum. At the time
of the examination, all the parts covered by the block
were more or less excoriated, and in a high state of
inflammation, so that one of the Committee thought
there was danger of the formation of an abscess in
the part. The patient did not complain of any abdo-
minal symptoms, nor of very great pain from the pres-
sure. The force of the instrument was afterwards
diminished, and the inflammation soon subsided. The
Committee has seen several other instances of excori-
ation from the action of different blocks, but none in
which serious inconvenience was produced by this
cause.-Prel. Rep.
The cases described in Note III. (p. 320,) and Note

136
APPENDIX.
W
VI. (p. 321,) have not been heard from since those
notes were written.
me
H
The foregoing details complete the history of all
that is important in relation to the cases which were
made the subject of comment in the Preliminary Re-
port.-Final Rep.
evn
ecoll and vd
Common Inguinal Hernia, of about one year's standing;
age of patient 27 years; radical cure in seven months.
vd boltimg00
19
CASE XIV.* Mrs., aged 27.
-, aged 27. Constitution vi-
gorous. Patient arrived from Ireland in 1834. She has
been accustomed to much exercise. While preparing
for her voyage she was suddenly seized with pain in the
right inguinal region, and a small tumour appeared
there; but the complaint received no attention until
October 1st, 1835, when, having suffered several times
from partial strangulation of the bowel, she consulted
Dr. ISAAC PARRISH, by whom she was referred to my
care.
October 14th.-Saw the patient for the first time.
Tumour about as large as a hen's egg; painful to the
touch. She had walked several squares in the morn-
ing; states, that after such exercise she is accustomed
to faint, and is generally compelled to lie in bed two
or three hours, to recover herself.
* In the following cases, where reference is made to "Chase on
the Radical Cure of Hernia," those cases are embodied with others
of the Final Report.
H. C.

APPENDIX.
137
20th.-Applied the common Inguinal truss, in the
presence of PROF. HORNER, and Dr. CRITTENDEN of
Cincinnati, who kindly accompanied me. Dr. HORNER
reduced the bowel. The instrument being applied, the
patient rose from the bed. The retentive power and
adaptation of the truss were fully tested and ap-
proved.
21st.-Called, and found the patient attending to her
domestic concerns. The truss gave no pain, and oc-
casioned but very slight soreness. Patient says she
feels comfortable.
nedebeds
22nd.-Considerable irritation beneath the block.
24th.-Patient complains of soreness-did her family
washing this day.
26th.-Examined the parts; found them considerably
inflamed, particularly above the pubic bone. The pa-
tient does not complain of the pressure; has been to
market to-day.
31st.-Removed the block and substituted one rather
larger.
November 10th.-Instrument worn with ease.. The
retention has been perfect since the first application.
Tou
March 4th, 1836.-Instrument discontinued.
30th.-Examined the patient; no perceptible differ-
17

138
APPENDIX.
ence between the two sides. She is now, by calcula-
tion, in the seventh month of pregnancy.
April 11th.-Confined to her bed with false labour
pains.
19th. She has had an extensive abscess in the left
mammary gland, which I laid open this day; Dr. R.
COATES in consultation.
May 4th.-At 2 o'clock, A. M., the patient was taken
in labour; the pains were severe. After the rupture
of the membranes the labour was very rapid. It ter-
minated at 5 o'clock, P. M.
5th. The patient had severe after-pains during the
night.
11th.-Visited the patient in company with Dr.
SMART, of Maine. Found her going about as usual.
Dr. SMART pronounced her free from rupture.
July 11th.-The patient continues perfectly well.-
Chase on Hernia, p. 163, 164.
This patient, a female, was ruptured on the right
side, during unusual exertion while preparing for a
voyage from Ireland to this country in 1834. No sur-
gical advice was taken until October 1835, when she
was directed to the care of Dr. CHASE by Dr. ISAAC
PARRISH.

APPENDIX.
139
April 19th, 1836.-Patient examined this day by the
Chairman. The Inguinal truss of Dr. CHASE was ap-
plied on the 20th of October, 1835. The woman states
that she suffered some pain, but not a great deal, from
the action of the first truss. Another, with a block
and spring more suitable to the formation of the indi-
vidual's pelvis, was substituted on the 31st. The irri-
tation then subsided, and the truss produced no more
complaint. The retention was complete, from the first
application on the 20th of October. The woman being
far advanced in pregnancy, the truss was laid aside on
the fourth of last month. No protrusion has taken
place. She has a very large abscess of the left breast,
which was opened by the lancet this morning.
May 16th.-Seen by Drs. CHASE and R. COATES.
Patient was delivered with rapidity on the 4th instant,
and suffered severely with after-pains. It is thought
that this test of the security of the retentive power of
the abdominal tendons and fascia is sufficient to war-
rant complete reliance upon it, and the patient is di-
rected not to resume her truss on leaving her chamber.
July 11th.-Again visited by the Chairman. She is
pursuing her usual avocations, and is pronounced radi-
cally cured.
March 30th, 1837.-This patient continues perfectly
well.* On reviewing the notes, the Committee think it
* Soon after, July 11th, 1836, this patient moved to a distant part
of the city. I saw her but seldom until June 20th, 1837, when I

140
APPENDIX.
right to mention that the absence of protrusion during
the last months of pregnancy, and even during labour,
is a fortunate and not unfrequent result of the position
of the gravid uterus, which displaces the intestines from
their usual position. It was therefore the absence of
protrusion during continued and severe after-pains
which alone induced the conclusion that the cure might
then be safely considered radical. These remarks are
intended as a caution to the inexperienced, who might
naturally conclude that the absence of all symptoms
of hernia in the inguinal or femoral region, during the
latter months of gestation and the period of labour,
was a sufficient proof of the non-existence of the dis-
In umbilical hernia, continued retention during
the latter moments of labour would indeed be a strong
argument in favour of the radical cure.*-Final Rep.
ease.
was summoned in the night to visit her. I found her under the
care of two physicians, and learned that she had been gradually
declining for several months past. I saw her daily for a short time;
she was not wearing the truss. I examined the parts carefully at
several different times, but I could detect nothing unusual in the
state of them. She assured me that no return of the rupture had
ever taken place. She died on the 27th of June. Every effort was
made to gain an autopsy, but without effect.
*
August 9th, 1837.-Mrs., aged about 30 years, of a robust
constitution, at the suggestion of Drs. I. PARRISH and GALLAHER
called at my office to consult me relative to a femoral hernia under
which she was then labouring.
She met with this accident ten years ago in jumping from a cherry-
tree when she was enceinte. She has suffered much from the old
trusses, and had entirely abandoned them before I saw her. She
is now pregnant with her fourth child; her hernial tumour is as
large as a billiard-ball, and very painful. She is extremely anxious

APPENDIX.
141
Common Inguinal Hernia, of seven years' standing; age
of patient 12 years; radical cure in seven months.
CASE XV.-Master E., aged 12 years: constitution
vigorous; frame slender: accident occurred several
years ago: attributed by the parents to a fall from a
fruit tree; but the patient states that the tumour first
appeared during a ride on horseback soon after the fall.
November 27th.-Applied the common inguinal truss.
28th.-Truss worn during the night. Patient slept
well.
December 4th.-Parts beneath the block slightly red-
dened.
April 1st.-Examined the case: no perceptible dif-
ference between the two sides: the retention perfect
from the first. He has indulged in his usual sports
without restraint, during the frost and snow of last
winter. States, that since the four or five first days
to be relieved, for she says, "I suffer greatly in consequence of the
rupture, when I am confined, for weeks before, and for some time
after. The pain produced by the rupture is far greater than what
I experience at the birth of my children." She also adds that the
tumour always protrudes more as the time of her confinement ap-
proaches; and when in labour it increases very much in size, and
is extremely painful.
Thus it will be observed, that though the general rule laid down
by the Committee be correct, the protrusion sometimes does occur
during the latter months of pregnancy, and must be guarded against
accordingly.
H. C.

142
APPENDIX.
of the treatment, he has been scarcely conscious of the
presence of the instrument.
June 22nd.-Examined in the presence of Dr. R.
COATES. Both sides present, in all respects, the same
appearance. Patient has frequently laid aside his truss
for short intervals: has bathed in the Delaware, and
has used other exercises without it. Dr. COATES ad-
vised the discontinuance of the truss, believing the
case to be radically cured.-Op. cit.
Dec. 4th, 1835.-CHASE'S Inguinal truss was ap-
plied on the 27th of November last. Some redness
from irritation is visible when the truss is removed,
but no inconvenience is felt from it. The retention
has been constant and perfect from the first.
April 1st.—There has been no protrusion. No dif-
ference between the size and resistance of the two
rings can be distinguished on reverting the skin of the
scrotum before the finger. Some redness continues,
but the patient insists that he is seldom aware of the
presence of the instrument. There has been much less
subcutaneous absorption than usual in this case.
June 22nd.-Examined by the Chairman. The pa-
tient has often removed his truss for some hours at a
time; he has taken walks, and has gone on swimming
excursions repeatedly without it.
The opposite sides of the abdomen now appear per-
fectly similar in all respects. The redness and de-

APPENDIX.
143
pression beneath the block have both disappeared.
The case is believed by the Chairman to be radically
cured, and he strongly advises the discontinuance of
the truss.
March 31st, 1837.-This little patient has been re-
peatedly seen by members of the Committee since the
last date, and was critically examined by the Chairman
in February. He wore the truss occasionally for some
weeks after the 22nd of July, 1836. He is now per-
fectly well, vigorous and active.-Final Rep.
Ventro-Inguinal Hernia, of six years' standing; age of
patient 10 years; cure radical.
CASE XVI.-Master W-, aged 10 years; accident
occurred six years ago; cause unknown. This young
gentleman's father had spared no expense in obtaining
for him the best instruments, none of which permanent-
ly retained the hernia.
December 13th, 1835.-Ventro-inguinal truss applied.
16th.-Patient has suffered no inconvenience from
the truss: retention perfect.
January, 1836.-Skin inflamed beneath the block:
patient complained of some soreness when the instru-
ment was removed for examination.
April 2nd. Instrument removed in the presence of
Dr. JOHNSTON, one of the resident physicians of the

144
APPENDIX.
Blockley Hospital. A distinct depression of the skin
was seen on the parts covered by the block, and it
included the whole route of the inguinal canal and
extended to the edge of the pubis. The bowel had
never been down since the commencement of the treat-
ment.
June 20th.-Examined the case this day: the abdo-
minal rings on both sides appear alike: there is still
some slight depression of the parts pressed by the
block: he has bathed frequently in the Delaware with-
out his truss: feels no inconvenience from his former
rupture. Case considered as radically cured; but the
patient still generally wears his truss at his father's
request.
This patient has been under the eye of Dr. KLAPP
from the commencement.-Op. cit.
Feb. 26th, 1837.-This case is fully detailed in Dr.
CHASE'S Treatise, (p. 166, Case XX. q. v.) but has
only been seen by the Chairman of the Committee on
the present occasion. The Ventro-inguinal truss was
applied December 13th, 1835. The patient testifies
that there have been no signs of protrusion at any time
since that day. Dr. CHASE considered the patient
radically cured June 20th, 1836, six months after the
commencement of the treatment, as prior to that time,
by the patient's own showing, he had repeatedly left
off the instrument during bathing excursions; but the
boy's father compelled him to continue the use of the
truss. He has more recently laid it aside on many

APPENDIX.
145
occasions for several days together; has cast it off
entirely for the last two weeks, and has been enjoying
himself in skating on three different days, without any
protrusion whatever. The external ring is about the
natural size, and there remain no marks of a truss ever
having been used in the case, except in the persistence
of a slight subcutaneous puffiness in the parts beneath
the block. The patient is now radically cured, what-
ever may have been his condition on the 20th of June,
1836.-Final Rep.
Direct Inguinal Hernia, from coughing in an attack of
asthma; case of four years' standing; age of patient
45 years; radical cure of the hernia; persistence of
the asthma.
boaras
moradterst
CASE XVII.
-, stone-cutter, age 45 years,
a strong man, accustomed to much exertion; but
having had a fracture of the patella, he has recently
avoided lifting heavy weights by the direction of Dr.
HARTSHORNE. This patient is asthmatic; cause,
coughing in an attack of asthma; accident occurred
four years ago; tumour large; patient had worn one
of the old fashioned trusses, (see fig. 3, p. 45, Chase
on Hernia;) but the bowel frequently escaped from
beneath the pad. He consulted Dr. TURNPENNY, by
whom he was referred to my care.
October 28th, 1835.-Examined the case for the first
time. The external ring was unusually large, admitting
two fingers; Ventro-inguinal truss applied.
hotsest
18
hd boon

146
APPENDIX.
30th. Since the application, the bowel made a par-
tial escape during a coughing-fit, but was returned by
the patient himself-Substituted another truss with a
stronger spring.
SM OF
November 5th.--Yesterday evening the patient was
seized with a paroxysm of coughing, and a slight
escape of the bowel took place. The pressure of the
block was again increased by bending the neck of the
spring, and its margin was also more nicely adapted to
the edge of the pubic bone.
November 12th.-No further descent of the bowel
has taken place.
Here the regular entry of the notes ceased, because
nothing interesting occurred.
and suoi
quoine o tulbum of bom 005 am g snora s
July 11th, 1836.--The patient examined in the pre-
sence of Dr. R. COATES. The retention has been per-
fect since the last date. The patient has been in the
habit of taking off the truss at night, and re-applying
it before rising in the morning. About four weeks ago
he laid aside the truss without orders, and continued
his usual avocations for ten days. I re-applied it, and
ordered its continuance; but the patient again threw
it off at the end of four days, and has not since em-
ployed it. He has attended to all the duties of a
master stone-cutter, without the slightest incon-
venience during the whole period. The ring is con-
tracted to the natural size, rather unusually well de-
fined, but seems somewhat less resisting than usual at

APPENDIX.
147
its centre. Advised the patient to continue the truss,
as a precautionary measure, for a few months longer.
-Op. cit. p. 167.
afted
com d
31
The patient was first seen by the Chairman of the
Committee, July 10th, 1836. He then stated that he
had laboured under hernia for nearly five years. The
orifice is stated to have been large and direct. It ori-
ginally admitted two fingers. The old common truss
had been employed, but the bowel frequently descend-
ed beneath the pad. Dr. CHASE first saw him October
28th, 1835. Hood's Parabolic Block, with CHASE'S
Truss-spring, was applied. The retention was perfect
till the 30th of October, when an attack of asthma
occasioned a protrusion. A truss with a firmer spring
was employed, and the retention continued constant
during the whole course of the treatment. After the
introduction of CHASE's new Ventro-Inguinal truss,
it was applied in this case, but the Committee possess
no note of the date of this substitution.
July 11th, 1836.-Examined by the Chairman. The
truss now in use (CHASE'S Ventro-inguinal) has never
given any inconvenience-all those previously employ-
ed had done so. The patient performs all his duties
as a master-mason with composure and ease--a former
fracture of the patella leading him to avoid very heavy
lifting, by the advice of Dr. HARTSHORNE. In the early
part of last month he left off his truss for ten days,
and pursued his business without any accident; for
which he was censured, and directed to continue the
application of the instrument. The edges of the ring

148
APPENDIX.
are now well marked and somewhat thickened, but are
very little less contracted than on the sound side.
yo
April 1st, 1837. Some two months ago this patient
was seen by the Chairman. He continued to wear his
truss occasionally when performing heavy lifting, and
during attacks of asthma. Since that time he has been
lost sight of by the Committee. No signs of protru-
sion have ever appeared during the considerable
periods for which the truss has been relinquished,
although no particular care has been used to avoid ex-
ertion in the pursuit of his usual avocations in the
marble yard.-Final Rep. Nage Bow canine
multes lo slots no ned
s no nede todo: 0
0.3% dioc
Direct Inguinal Hernia, of four weeks' standing, caused
by an accident in riding on horseback; age of patient 30
years; radical cure in seven months.
h
enl-onh
origi
CASE XVIII.-Mr. B, aged 30 years; accident
caused from the stumbling of his horse; case of four
weeks' standing.
This gentleman had long been a distinguished
teacher in the city, but had been compelled to relin-
quish sedentary, for more active pursuits. He was re-
commended to my care by Dr. EDWIN A. ATLEE. The
bowel had penetrated the canal about midway between
the two rings.
December 4th, 1835.-Applied the Ventro-inguinal
truss. Saw the patient every third or fourth day for
four weeks. There has been but little irritation, and

APPENDIX.
149
no excoriation at any time, from the pressure of the
sl.ed
MATURG
instrument.
door ond
bra trode m
After the instrument was properly adjusted, it was
worn constantly for four months, since which, it has
been laid aside occasionally at night.
del
June 4th, 1836.-Examined the patient. He is ap-
parently cured: the retention has been perfect since
the instrument was correctly adjusted, and the patient
has been insensible of its presence during most of the
time. He informs me that Dr. ATLEE has seen him
repeatedly during the treatment, and the Chairman of
the Committee on hernia is familiar with the case.
July 17th.-The patient called on me this day. He
has relinquished his truss, and is considered radically
cured.-Op. cit. p. 171.
The bowel burst into the abdominal canal, near the
middle of its track, not having passed through the in-
ternal ring at all. The internal orifice did not corres-
pond with the external ring, but remained concealed
beneath the tendon of the external oblique muscle.
The Ventro-inguinal truss was applied by Dr. CHASE,
December 4th, 1835, and it was ordered to be laid aside
July 17th, 1836. After the adjustment of the instru-
ment, which required more care than necessary in
common inguinal hernia, it was worn day and night
for about four months, and in the day time only, for
nearly three months longer. tooaegge bas 20m

150
APPENDIX.
Jan. 1st, 1837.-Examined by the Committee. The
patient states that he has never suffered a protrusion,
from about the 10th of December, 1835, (one week
after the first application of the truss,) to the present
moment. He wore the instrument occasionally from
the time he was ordered to relinquish it until about the
1st of December last, since which he has not applied
it at all. The ring is now quite as firm and small, if
not more so, than that on the opposite side. The parts
formerly pressed upon by the truss, display not the
slightest traces of its presence. Much adeps covers the
lower part of the abdomen. This patient is consider-
ed radically cured.-Final Rep. garmb betro091
diiw zoilind
inst si simrod ro
sired no sottima ort
Umbilical Hernia, of many years' standing; enormous
orifice; complete retention by Chase's Umbilical Truss,
with a block six inches in diameter; patient restored to
usefulness, but deemed incurable.
0 boTUS
CASE XIX.-Mrs. ——, aged 55 years; duration of
the accident many years. ell for claart le slibin
sond evitiro fent of de te pain lemnet
May 21st, 1836.-Called to the case this day by Dr.
HAYS. The patient has laboured under a small her-
niary tumour at the umbilicus for many years, and the
bowel had been imperfectly retained by means of a
bandage only.
helpper doidy drom
On the 25th instant, a sudden protrusion took place,
increasing the size of the tumour to that of a quart
mug, and apparently extending the orifice much beyond

APPENDIX.
151
its previous limits. The tumour became very tender
to the touch, and there was threatening of strangula-
tion. Dr. HAYS reduced the bowel, and I then applied
an instrument to act as a temporary protection, until
a truss armed with a block of sufficient size could be
prepared. The woman was enormously fat, her abdo-
men measuring three feet ten inches in circumference!
30th.-Having ordered an instrument expressly for
this case, I applied it in the presence of Drs. HAYS
and R. COATES. Dr. C. examined the aperture, which
was of an oblong form; and the rent or opening in the
linea alba was at least two inches and a half long, by
one and a half in width! The block required to retain
the bowel was six inches in diameter! Much difficulty
was experienced in adjusting the instrument, owing to
the folding and doubling of the integuments and the
empty sac, after the reduction; and some fear was
entertained that the whole mass of sac and integument
might be reverted within the abdomen by the action
of the block.
After the application, the patient was requested to
rise, and walk about the room. In the afternoon she
went down stairs and returned again. The retention
was perfect.
Anor
July 17th.-The case was carefully examined in
company with Dr. R. COATES. The orifice had con-
tracted very much, and the sac had diminished in size.
Some of the folds of skin had been for some time ex-

152
APPENDIX.
coriated by the pressure of the block; but this accident
was much relieved by dusting the surface with carbon-
ate of zinc. The truss had been removed several
times in order to wash the part; but this had always
been done with great caution, and by my own hands,
while the patient was in the recumbent posture.
July 25th.-There has been no protrusion since the
first application of the truss, and the patient has con-
stantly attended to her domestic concerns with ease
and comfort. The contraction of the skin and sac,
with the absorption of fat produced by the pad, has
rendered a larger block desirable, and it is proposed
to substitute one of seven inches diameter.
1000
161lb 150]
In addition to the surgeons already named, the case
has been examined by Dr. GAGE, of New York, and by
Dr. BAIN, of Baltimore.-Op. cit. p. 174. os vigmo
edt tell boutstring
The orifice, as measured by the Chairman, May 30th,
1836, was two inches and a half long, by one and a half
wide, running along the linea alba above and below the
umbilicus; the sac, with the integuments covering it,
was very large, and flabby after reduction. Dr. COATES
thought that caution would be required in applying the
truss, lest the whole mass should be reverted bodily
within the abdomen! The patient was excessively fat.
A truss with a block six inches in diameter, was applied
for some months; one of seven inches in diameter was
afterwards found preferable. The overlapping of the
loose sac, which formed a soft cushion beneath the

APPENDIX.
153
block, gave rise to excoriation and mucoid transforma-
tion of the skin, which was relieved by dusting with
the impure carbonate of zinc. On the 17th of July,
the orifice was contracted to almost half its former
dimensions, and the sac had become diminished at
least one-fourth.
April 29th, 1837.-The patient was examined, and
the truss removed by the Chairman this day. The
sac, loose, flabby, and perfectly empty, even of serum,
but not obliterated by adhesion, still remains, but is
much diminished in size. There is no irritation of the
surface, the parts being perfectly accustomed to the
pressure of the instrument. The enormous obesity of
the patient makes an accurate examination of the linea
alba exceedingly difficult, but no signs of the hernial
orifice could be ascertained by the finger. The truss
was reapplied. The patient is perfectly comfortable,
and attends to laborious duties with impunity.-Final
Rep.
Umbilical Hernia, of twenty-one months' standing; age
of patient 2 years; radical cure in five months by
Chase's Umbilical Band.
CASE XX.-February 15th, 1836.-I was first called
to the case to-day. The rupture has been much ne-
glected from the first; but the mother had attempted
the treatment of the case by pressure with the hand,
&c., without effect. The orifice is so large that the
end of the thumb can be readily depressed into the
abdomen. This unusual deficiency of the tendons is
19

154
APPENDIX.
the principal peculiarity of the case. An umbilical
band depressing the integuments of the umbilicus about
five lines, was applied.
20th. The bowels have been perfectly retained.
There is slight redness of the skin.
March 19th.-Instrument raised from the rupture.
No escape of the bowel took place.
April 8th.-Band removed. Child cried, and no pro-
trusion took place. Band reapplied.
July 16th.-Since the 12th, the patient has not used
the band. Considered cured.
The irritation produced in this case was never car-
ried beyond a full degree of redness of the skin, and
never occasioned material inconvenience to the child,
who is now perfectly well, the parts having assumed
their natural position.-Op. cit. p. 173.
Of this case the Committee have no knowledge other
than that derived from the mother and the surgeon,
until after the completion of the cure. Attempts to
relieve this patient (a female) by pressure with the
hand, when it cried or used exertion, were made with-
out effect; but it is not certain that they were very
faithfully made. The orifice is described to have been
large enough to admit the end of the thumb with
facility. The band was applied February 15th, 1836.

APPENDIX.
155
Retention was constant and perfect, and the band was
finally removed on the 12th of July.
January, 1837.—Day not noted. Case examined by
the Chairman. There has been no protrusion since
the band was first adjusted. No signs of the sac ap-
pear. The linea alba, where the opening was located,
is now firm, but not quite so much so as the remainder
of that tendinous expansion. The child is active and
playful. She is considered radically cured.-Final Rep.
Congenital Hernia; truss applied at the age of two
months; radical cure in twelve months.
CASE XXI.-April 1st, 1837.-This case is noted in
order to show that very young children endure the truss
without inconvenience, which is contrary to the opi-
nion expressed in the Preliminary Report. The nurse
states that Dr. CHASE applied the Ventro-inguinal
truss, which was shown by her to the Chairman, when
the child was two months old. It is proper to mention
that this instrument is preferred in all the varieties of
inguinal hernia, occurring in children under five years
of age, as it is better adapted than any other to the
prominent abdomens and diminutive canals of these
little patients. The truss was finally removed at the
age of one year. The infant is now fourteen months
old. The nurse insists that the truss never occasioned
any inconvenience to the child, and very little redness
of the part. The block rested directly on the skin
for the greater part of the time, but occasionally the
nurse inserted beneath it a layer or two of linen. The

156
APPENDIX.
child is now radically cured. It is scarcely necessary
to remind those who have attempted the employment
of trusses, with soft pads, in young infants, how much
more severely the skin is usually affected by them.-
Final Rep.
Common Inguinal Hernia, of many years' standing; age
of patient 27 years; radical cure in twelve months.
CASE XXII.-Mr. — -, merchant, aged 27 years.
Accident occurred when a lad at school; cause un-
known. An instrument was applied as soon as the
disease was discovered, and he had constantly worn
some variety of truss until he came under my care,
Jan. 16th, 1835; but his bowel had never been retained
for any considerable length of time by either of them.
20th.-The common Inguinal truss applied.
25th. The patient has had one descent of the
bowel since the last date. An instrument with a
stronger spring applied.
November 13th.--No protrusion has taken place since
last date. Truss worn with ease. The parts have
exhibited scarcely any marks of irritation externally.
July 25th, 1836.-I have not seen the patient since
November last. Dr. HULME met him to-day. He stated
that he relinquished the truss six months ago. He
has been travelling for some months on horseback, in
the western country, often at the rate of fifty miles a

APPENDIX.
157
day, and says that he has not suffered any incon-
venience from his long journey, nor has he perceived
any symptoms of his former disease.
200
I shall give, under the head of diseases resembling
hernia, an example of the danger of careless exami-
nations in forming a diagnosis in this disease; the fol-
lowing instance displays, in the strongest light, the im-
propriety of putting the business of applying trusses,
into the hands of those who know nothing of surgery.
The former was a proof that life may be endangered
by mistaking hernia for other diseases; and the latter
shows that the comfort of the patient may be sacrificed,
and his condition rendered worse, by mistaking other
diseases for hernia.-Op. cit. p. 177.
The facts of this case, so far as the treatment is
concerned, are taken from the statement of the patient,
a highly intelligent gentleman, and the dates are added
from the notes of Dr. CHASE.
The accident occurred in childhood. From the time
when the disease was first perceived, to the 20th of
January, 1835, a variety of trusses were successively
employed, and neither care nor expense was spared in
the selection. Not one of these instruments prevent-
ed the frequent descent of the bowel. The intestine
escaped but once after the first application of CHASE'S
Inguinal truss, which was made on the day just men-
tioned. This protrusion occurred within three days of
that time, and led to the employment of an instrument
with a stronger spring. The latter was worn without

158
APPENDIX.
inconvenience, and produced scarcely any irritation.
The truss was finally relinquished in January, 1836.
tee.
February 12th, 1837.-Patient seen by the Commit-
He states that since he laid aside the instrument
he has performed a fatiguing journey to the west on
horseback, sometimes travelling fifty miles in a day.
He has used much exercise of all kinds, and yesterday
inhaled the nitrous oxyde gas. He is muscular and
powerful.
ausba
The radical character of the cure is most amply
proved in this case.*-Final Rep.
Common Inguinal Hernia, of four months' standing; age
of patient about 45 years; radical cure in less than six
months.
CASE XXIII.-February 26th, 1837.-This patient
called at the office of the Chairman. He is by trade
a weaver, and stated that he became affected with
hernia about the 1st of April, 1836. CHASE's Inguinal
truss was applied August 1st, 1836, and it was finally
relinquished a few weeks ago. The man has continued
at his trade up to the time of this note.
There are some traces of the secondary hyperemia
still remaining on the parts which have been pressed
* This gentleman was examined last winter during the lectures
at the Jefferson Medical College, by Professor GEORGE M'CLELLAN,
and several Medical Students.
H. C.

APPENDIX.
159
upon by the block. No other external signs of its
employment are discoverable.
The external ring, on the affected side, offers much
more resistance to the finger, and is much more con-
tracted than that on the other side. The patient is
pronounced radically cured.*-Final Rep.
Sub-Umbilical Hernia, of many years' standing; female
about 35 years old; sac, globular and pediculated; con-
traction of orifice and apparent obliteration of the sac;
case still pending.t
CASE XXIV.-Notes by the Chairman.-November
29th, 1836.-This female had a hernia through the
linea alba, commencing about half an inch below the
cicatrix of the umbilicus, and the circular orifice being
about half an inch in diameter. The sac was surround-
ed by integuments much loaded with fat and densely
fibrous cellular tissue, forming a globe nearly three
inches in diameter, attached by a short pedicle as large
as the middle finger.
The bowel filled this sac very readily on slight ex-
ertion, and was as readily reduced. Strangulation had
been repeatedly threatened. When the bowel was
returned, the sac was found to contain abdominal se-
* This patient was examined by Professor MCLELLAN at the
time stated in the foregoing note, and also about one month ago;
the increased thickening of the ring was still observed.
t Now cured.
H. C.

160
APPENDIX.
rum, which could be instantly expressed, but slowly
returned on the removal of pressure. The distension
was not sufficient to support the weight of the globe,
which hung down against the abdomen. CHASE's Um-
bilical truss was applied on the orifice, the pedicle being
pressed downward out of the way.
January 13th, 1837.-The tendinous orifice has been
contracted to the diameter of three-eighths of an inch.
The globular sac has been diminished very consider-
ably. Its pedicle has been thrust down by the pressure
of the block, until it appears as if attached entirely
below the orifice of the sac which has become flattened;
while the walls are thicker and the subcutaneous cel-
lular and adipose tissue is much more condensed; so
that what was formerly a globe, now strongly resem-
bles a condilomatous tumour, except that the contract-
ed serous lining of the cavity remains apparently un-
altered in texture, and has formed no adhesions in the
interior. The neck of the sac is probably closed, as
there is no appearance of abdominal serum within.
When the hernia is cured, this excrescence may be
safely and readily removed by the knife; for the pre-
sent it is reverted upward, and will be employed like a
cushion beneath the block and over the orifice.
This singular hernia may probably have been pro-
duced by a small fatty tumour of the peritoneum forcing
its way between the fibres of the tendon, and followed
by the bowel forcing the tumour, with its attachment,
bodily through the opening. See ABDOMEN, fatty tu-
mours of, in the Amer. Cyclop. of Pract. Med.

APPENDIX.
161
April 29th, 1837.-Examined by the Chairman. The
orifice is not discoverable; its site being again con-
cealed by the base of the tumour, since it has been
turned up in the form of a flap beneath the block. The
sac now appears to be obliterated by adhesion or con-
traction, and the tumour is inflamed and slightly ulcer-
ated, but gives the patient no pain. The case is from
the country, and cannot have the advantage of con-
stant surgical superintendence. Dr. COATES recom-
mended that if the tumour should prove troublesome,
it should be removed by the scissors or ligature.*-
Final Rep.
200
Note by Chairman; Common Inguinal Hernia; Truss
applied at the age of fourteen months.
911
CASE XXV. This note is made merely to illustrate
the applicability of trusses to young infants.
* This patient states that she first observed the tumour several
years ago, and that it was then the size of "a full grown pea." It
had gradually increased until it had gained the size mentioned by
the Chairman of the Committee. The abdominal opening is per-
fectly closed; the sac now presents but a very small remnant of its
former dimensions, and seems to have been removed by interstitial
absorption, aided by pressure. No inconvenience will even result
from it in its present state; this remnant of skin can have no effect
upon the state of the tendons, which alone gives permanent se-
curity. She is radically cured.
It should be remarked that the block of the instrument employed
in this case was of peculiar construction: it was somewhat more
flattened than those which I employ under ordinary circumstances.
H. C.
20

162
APPENDIX.
Nov. 18th, 1836.-The child is now eighteen months
old. He has worn CHASE's Ventro-inguinal truss four
months, and has never suffered any considerable incon-
venience from the pressure of the instrument, although
the story of the mother betrays both ignorance and
unwarrantable disobedience of orders in the manage-
ment of it, and in consequence of these circumstan-
ces, temporary protrusion has frequently occurred.
Still, the child's health which was previously injured,
apparently by abdominal irritations occasioned by the
hernia, has been much improved during the action of
the truss. The action of the block in this case, as in
most instances of common inguinal hernia in young
children, was confined to the neighbourhood of the
internal, and did not extend quite to the external ring.
The attempt to approximate the edge too closely to
the symphysis pubis, would, probably, occasion some
trouble in the management of the perineal strap.
The Committee have never seen ventro-inguinal her-
nia in very young children.*-Final Rep.
* There has been no protrusion of the bowel, in this case, since
it was examined by the Chairman.
August 16th, 1837.-Child of Mr. S-, aged six weeks. Two
days previous to the above date, this little child was ruptured it is
supposed by vomiting. Doctor BOURNONVILLE, the family physician,
was called in attendance and referred the patient to my care.
On
the 16th, I applied a Ventro-inguinal truss, which retained the
bowel perfectly. I have watched this case with unusual interest
up to this time. The truss has given no material inconvenience,
no abrasion of the skin has followed its employment, and no marks
are observable over the site of the rings and inguinal canal, except
a little redness. It is with much pleasure that I have observed the
candour of the Committee in correcting the statement which they

APPENDIX.
163
Inguinal Hernia supposed to be Congenital; age of patient
about 22 years; Permanent Retention by Hull's Truss
for eight years; Ring not obliterated; Testicle reduci-
ble; Cure believed to be radical by the use of Chase's
Inguinal truss in eight months.
CASE XXVI. April 8th, 1837.-This patient is an
intelligent young graduate from the country. His her-
nia was retained constantly by Hull's truss for eight
years. He believes there was no protrusion in all that
time; yet on the day of its relinquishment, the bowel
protruded.
He believes that he was then able to return the tes-
ticle into the abdomen at will; but in this he may have
been deceived by its disappearance beneath the skin
felt it their duty to make against the employment of trusses in
young children in the Preliminary Report (p. 322). Although I had at
that time some cases under treatment, the Committee had not had
any opportunities of witnessing the action of the instruments. I
have applied instruments in many cases of rupture in children, and
in no instance have I seen material inconvenience resulting from
their action.
One circumstance, however, should here be noticed, which will
be found to occur during the use of all instruments in very young
patients, more particularly when they press upon the pubic bone.
It sometimes happens that during the first twenty-four hours after
the application of the truss, the scrotum becomes swollen and
parently cedematous. By the removal of the truss for a few hours,
and cold applications applied, the swollen parts and oedema will
disappear, and the truss should again be applied.
ap-
No danger need be apprehended from these appearances. I
never saw the swelling re-appear.-H. C.

164
APPENDIX.
of the abdomen. He states that CHASE's Inguinal
truss was applied Feb. 18th, 1836. It was worn con-
stantly by day and night until the month of October,
1836; he then relinquished it entirely. This day the
parts present no trace of the action of the truss. The
external ring is somewhat larger than its fellow of the
opposite side, but no symptoms of a tendency to pro-
trusion have been present at any time since the
moment of relinquishing the instrument.*-Final Rep.
* Professor GIBSON examined this patient prior to the application
of the instrument, and referred him to my care. He is a graduate
in Medicine of the University of Pennsylvania.
April Sd, 1837.-By the advice of Professor HODGE,
Esq. a gentleman possessing great muscular power, and of active
business habits, called at my office, and requested me to examine
a tumour in his groin, which he informed me had been there for
several days. On examination, I found he had femoral hernia of
the right side, which, after several efforts, I succeeded in reduc-
ing.
This gentleman received the injury fifteen years ago, in con-
sequence of which, he obtained Dr. Hull's truss. He had worn
these instruments faithfully for fifteen years, and they had to all
appearance retained the bowel. Believing that the rupture might
be cured, he was induced to throw aside his truss. On the second
day following the discontinuance of the instrument, the accident
occurred.
This note is intended to show the impropriety of relying upon
security after the employment of soft-padded trusses; for, notwith-
standing the bowel may not make its appearance externally, it will
pass through the ring, enter the canal, and then rest against the
soft structure of the pad, which, being elastic, will yield at every
unusual effort of the patient.
Under these circumstances, a cure can never be expected.
Another case recently occurred to Dr. WARREN of New Orleans;
and every surgeon who has had experience in the treatment of her-
nia, may have met with similar cases.-H. C.

APPENDIX.
165
By Dr. Parrish; Double Hernia; ill health from its im-
perfect retention with trusses; Chase's Double truss em-
employed; perfect retention; improved health; case still
pending.
Lilys 18ory be
o ada ban
CASE XXVII.-S. M., a lady about 32 years of age,
applied to me in the summer of 1836, affected with
ventro-inguinal hernia on the right side, and common
inguinal on the other. She stated that about thirteen
years ago she felt something give way while lifting a
heavy weight. She felt sick and vomited, and was
confined to her bed for several days. On getting up
she discovered a small tumour in the left groin. She
consulted an eminent surgeon, who applied a truss
with a soft pad. She wore this instrument for five
years, and it retained the bowel. About eight years
ago she went into the country and threw off the truss,
but found herself still liable to protrusion in this situa-
tion; after which, she took a long walk over a hilly
road, and found herself affected with a hernia of the
opposite side. She then applied a double truss, which
she has worn ever since. During the whole of this
period the patient has been subjected to great incon-
venience, and frequently to severe attacks of pain from
the imperfect retention of the bowel, and from the dif-
ficulty of adapting instruments to the parts. Her health
is much impaired. She is subject to attacks of colic,
poor appetite, pain after eating &c. I advised a trial
of Dr. CHASE's truss. at si ni
7th Mo. 9th, 1836.-The patient called to inform me
that she had been wearing Dr. CHASE's double truss

166
APPENDIX.
for about four weeks. It produced, for the first few
days, great inflammation and soreness about the groins.
The parts, however, soon became accustomed to it,
and she experienced great relief from the instrument.
Her appearance is much improved; her digestion good,
and she enjoys more comfort than she ever experienced
under the use of any other instrument. The bowel is
perfectly retained. She finds it very important to have
the instrument accurately adapted. She found some
difficulty in accomplishing this at first. ad 090
anw bus balimos bus
1st Mo. 12th, 1837.-S. M. called on me to-day to
say that she still continues to wear Dr. CHASE's truss.
Her health is now good; she is entirely free from dys-
peptic symptoms; experiences no pain from the instru-
ment, and uses active exercise without causing pain.
There has been no descent on the removal of the in-
strument for three months past. She considers the
instrument far superior to any other in point of com-
fort.*
Bongo
* It is not my intention, at present, in connexion with the above
case, to discuss the pathological effects following upon the ill re-
tention of hernia by instruments, as I have enlarged upon this sub-
ject on a former occasion: but there are few persons who have
laboured under hernia, even for a few months, who do not suffer
considerably under colic, pains in the inguinal region extending
along the canal, pains in the loins, dyspepsia, simple costiveness,
or costiveness combined or alternating with diarrhoea, together with
local pains and distress, pains in the limbs, head-ache, nervous de-
bility and giddiness.
It has often been a matter of astonishment, both to my patients
and myself, to observe how soon all these symptoms yield to the
perfect and accurate retention of the bowel by a proper instrument.

APPENDIX.
167
By the Chairman. Umbilical Hernia of eight years' stand-
ing; age of patient ten years; cure believed to be radi-
cal in five months.
CASE XXVIII. Feb. 24th, 1837.-This little patient
is stated by her mother to have laboured under a small
umbilical hernia for eight years. She has been wearing
CHASE'S Umbilical truss since the second of December
last. No signs of the sac are visible on removing the
instrument, but a hernial orifice at the umbilicus admits
the tip of the little finger. There are no signs of ir-
ritation about the parts pressed upon. The hernia
had been prevented from increasing before the use of
the truss, by careful bandaging.
April 20th. The patient again examined. The
child has been using violent exertion, and the margin
of the block has bruised the surrounding skin a little.
There is no trace of irritation, but some slight secon-
dary hyperemia is visible. No trace of a hernial orifice
can be discovered. The patient is judged by the Chair-
man to be radically cured, but Dr. CHASE declines re-
linquishing the use of the truss for the present.*-Final
Rep.
These symptoms are so clearly defined, that several surgeons in
this city have pronounced their opinion, and proved the existence
of hernia in cases in which the patients and their friends, from feel-
ings of false delicacy, have endeavoured to conceal the fact.
H. C.
* Aug. 3d, 1837.-I examined this little Miss to-day, and am
now satisfied that the bowel is perfectly secured.
instrument removed.
Ordered the
H. C.

168
APPENDIX.
By the Chairman. Inguinal Hernia of two years' stand-
ing; age of patient 13 years; radical cure by Chase's
Inguinal truss in six months.
CASE XXIX. April 27th, 1837.-This little boy
was brought before the Chairman this day. The facts
connected with the previous history of the case are
taken from the account by the child: the dates are from
Dr. CHASE's record.
About two years ago he fell from a tree, astride
upon a fence. The accident was soon followed by
hernia on the right side, which rapidly enlarged, and
the intestine descended into the scrotum. Dr. CHASE
states that the finger readily entered the abdominal
canal. His Inguinal truss was applied on the 12th of
May, 1836. On the night of the 13th it was laid
aside till morning. From the 14th of May till the
7th of November, it was worn constantly, by day and
night. Since the last date it has been entirely aban-
doned.
The two external rings appear now similar in all
respects. There have been no symptoms of weak-
ness, and the parts acted upon by the instrument re-
tain no trace of its former presence. This child
serves as an errand boy. He is radically cured.--
Final Rep.
01
0 welt orged

APPENDIX.
169
By the Chairman. Congenital Umbilical Hernia; Chase's
Umbilical Band applied at the age of two months; cure
deemed radical in two months.
ts
CASE XXX.-April 28th, 1837.-This little patient
is now 15 months old. Before the age of two months,
the usual care in preserving the bowels in place by the
hand, by bandage and compresses, and by a belt and
soft pad, had been tried without obvious effect. The
father states that the Umbilical truss of Dr. CHASE was
applied when the child was two months old, and was
steadily continued for six weeks, or, at most, two
months, since which, the case has been left totally un-
protected-not the slightest symptom of protrusion of
the bowel has occurred.
There is a very slight degree of puffiness about the
umbilicus in this case, as though the cicatrix had not
yet acquired its greatest degree of firmness; but the
accidents of childhood in a vigorous infant, from the
age of four to that of fifteen months, are deemed suffi-
cient proof that the cure is radical.-Final Rep.
The following highly interesting case was furnished
by HENRY BOND, M. D., in reply to a note from the
Chairman of the Committee, requesting an account of
the particulars.
Femoral Hernia; supposed sloughing of strangulated
omentum; return of hernia after the cicatrization of the
abscess.
CASE XXXI.-On the 9th of April, 1836, I was
21

170
APPENDIX.
called to Mrs. M. Y., aged about 34 years, who com-
plained of severe pain in the abdomen, and told me she
had the cramp colic. I prescribed a full dose of lauda-
num and castor oil. A few hours after, I called and
found that she had been vomiting, and was in no re-
spect better. I was now informed by an attendant of
a fact which the patient had refused to communicate,
viz: that she had "a lump in her side."
Upon examination, I found a femoral hernia of the
left side, which was with much difficulty reduced by
taxis. A truss was applied as soon as it could be pro-
cured. I visited her every day, for a short time, to
ascertain that the hernia was retained.
On the 16th I was called to see her again, and found
her in the same condition as on the 9th. Soon after
my last visit the hernia returned while the truss was
on, which she immediately removed. After repeated
and persevering efforts, and many hours delay, it was
again reduced, and the truss again applied.
On the 18th, about mid-day, it suddenly returned,
when she was in the street, attended with such violent
symptoms that she with difficulty reached her house,
which was only at a short distance.
Within an hour I saw her, and again attempted to
reduce the hernia, but without success. I attempted,
immediately after this, to obtain a consultation, but
each of the eminent surgeons to whom I applied was
either absent or indispensably engaged. In the even-

APPENDIX.
171
ing, two medical friends visited her with me, and re-
duction was again attempted without success. She
was bled copiously; active purgative enemata were
repeatedly administered, and, afterwards, opiate ene-
mata. Cold was applied to the hernial tumour, and
warm fomentations to the abdomen.
In the forenoon of the 19th, further attempts at re-
duction were made by myself and by the most compe-
tent surgical aid in the city. Vomiting and retching
came on soon after the return of the hernia yesterday,
and continued all night, accompanied with a pain which
occasioned a constant groaning, and prevented sleep
entirely until morning, when a short nap was procured
by the strong opiate enemata. She has great thirst,
and rejects every thing swallowed. Pulse very fre-
quent; tongue parched; great heat and tenderness in
the abdomen; the tenderness being very great about
the umbilicus, and extending over the whole cavity.
The hernial tumour is tense and tender, but has less
sensibility and pain than the abdomen.
She was told that her case was regarded as hopeless
without an operation, and that this, in her case, would
be attended with great danger. She promptly decided,
as she had done before, that she would not consent to
an operation. Attempts at reduction were now dis-
continued. She remained without any essential change
or abatement in her symptoms until the night of the
21st.
On the morning of the 22nd, I found a great change

172
APPENDIX.
in her condition. The vomiting had ceased, her thirst
had abated, and her appetite had returned. The heat,
pain, and tenderness in the abdomen, which were un-
abated yesterday, were now greatly diminished; her
countenance has improved, and she has had a slight
alvine evacuation. The hernial tumour continues un-
diminished in size, density and sensibility.
April 28th.-She has had no return of the vomiting,
nor of the heat, pain and tenderness of the abdomen
since the 22nd. The tumour has been increasing very
considerably in size, and has been extremely tender,
but without any considerable pain so long as the pa-
tient is at rest. She has had stools every day, but not
without the use of purgatives. The appetite is vari-
able. The patient has been down stairs repeatedly,
but is unable to straighten the limb, owing to the ten-
derness about the top of the thigh. While the tumour
has been increasing in size during the last few days,
it has become rather softer, and its outline is less dis-
tinctly defined. During this day, she has experienced
a sharp, burning pain, such as commonly occurs when
an abscess is about to open spontaneously. About 9
o'clock, P. M., it burst and discharged a considerable
quantity of dark and very foetid matter.
roled ano
On the 29th, the patient informed me that she had
rested well: that this morning she pulled "a core" out
of the opening, at least six inches long, and as large
as her little finger: that it did not look like other cores,
as it was very dark coloured and foetid. I did not see

APPENDIX.
173
it, but had no doubt, from her description, that it was
a part of the omentum.
and bas Julnica
The discharge rapidly subsided, and the opening
healed entirely within ten days. Some stiffness, and
inability to produce complete extension of the limb
remained a few days after the opening occurred. As
soon as the discharge, and the sensibility of the part
would admit of it, I applied a truss with a view of con-
solidating the parts and to insure the certainty of ef-
fecting a radical cure.
On the 10th of May, she was so well as to be about,
attending to her ordinary laborious occupation. The
truss was worn only a very few days, as I was told
by some of my surgical friends that it was useless, as,
from the condition of the parts, there must necessarily be a
radical cure without the application of a truss.
July 3d.-I was again called, and found that she
had very great pain in the left groin, extending into
the iliac region. She had nausea and obstruction of
the first passages. There was a tumour in the groin,
below Poupart's ligament, about the size of a marble.
I made some attempts to reduce it, but without suc-
cess, and had some doubts whether it was a hernia.
I directed v. s. 3xviii. copious purgative enemata, and
afterwards a large dose of castor oil. In a little time
she was relieved of the pain, and the tumour disap-
peared.
July 31st.-The hernia returned yesterday, and was

174
APPENDIX.
so painful as to prevent any sleep last night. I was
called at 1, P. M. The tumour has become larger to-
day and more painful, and she has been vomiting all
the forenoon. She has had no stool since yesterday
morning. The tumour is just below, and parallel with
Poupart's ligament, and is about the size of the last
joint of my thumb, firm, and painful on pressure. The
patient complains of great pain in the abdomen, chiefly
in and above the left iliac region. I directed a copious
and active purgative enema, to be followed by a ca-
thartic draught; called again, in a short time, with a
medical friend, and found her in no degree relieved;
directed two dozen leeches to be applied to the tumour,
and afterwards cold to be applied; ordered a strong
purgative enema, and after that operated, a large dose
of castor oil. After the use of these remedies she
became a little easier. At a little past midnight she
ceased vomiting, and had a stool.
August 1st.-In the morning I found the tumour
soft, and it was reduced without difficulty.
Since the last date, the hernia has re-appeared seve-
ral times in spite of the different trusses she has made
use of. She has generally succeeded in returning it
herself; but, on three occasions, it has been attended
with the same distress and difficulty as on the 31st
of July.
One chief reason why the trusses have not been
more effectual is, that her occupation obliges her fre-
beamt

APPENDIX.
175
quently to carry heavy burdens, and to pass up and
down a very steep flight of steps.*—Final Rep.†
* The above case fully illustrates the fallacy of the opinion en-
tertained by many, relative to the proper course of treatment after
operation for strangulated hernia, or sloughing of an omental pro-
trusion, namely; that, "from the condition of the parts, there must
necessarily be a radical cure without the application of a truss." It
proves beyond dispute that hernia does sometimes re-appear even
after the sloughing of the contents of the sac. Appropriate instru-
ments should therefore always be employed after a protrusion of
omentum, even when the protruded parts have suppurated or slough-
ed away. It will be acceded that in those cases which require an
operation, the ring is rendered still larger by the incision made by
the operator for the relief of the strictured parts; but it is difficult
to account for the re-occurrence of protrusion after the suppura-
tive process has been once established at the neck of the sac, on
any other supposition than, that it takes place before the edges of
the ring have had time to re-unite with firmness sufficient to resist
the force of the abdominal muscles. The safety and utility of the
truss in cases of strangulated omental hernia after sloughing or ab-
sorption, is illustrated by Cases XXXII. and XXXIII.
† Having observed, at the close of the Final Report, that the
Chairman of the Committee intended, on a future occasion, to
make some comments upon Case XXXI., reported by Dr. BOND, I
addressed him the following note:
MY DEAR SIR,
I observe, in the Final Report of the Committee on the Radical
Cure of Hernia, a notice that you probably intend to publish some
comments upon the case narrated at the conclusion of the Appen-
dix of that Report.
As the whole subject is closely interwoven with the republication
of your reports, and as the time of your departure from the country
draws near, may I be permitted to inquire whether any communi-
cation from your pen on this subject may be expected within any
short period of time?

176
APPENDIX.
I would also inquire if, in your opinion, the instrument em-
ployed in that case was so constructed as to render its failure in
retaining the hernia an argument against the claims of trusses
armed with wood?
REYNELL COATES, M. D.,
Very respectfully,
6db
COMPARATIVE ANATOMIST TO THE U. S. SURVEYING
AND EXPLORING EXPEDITION.
HEBER CHASE.
Philadelphia, September 4th, 1837.
To which the Chairman returned the following reply:
SIR,
In reply to your note of this morning, I would state that it had
been my intention to have communicated to one of the medical
journals, the substance of a lecture on the means by which the
radical cure of hernia might be accomplished after surgical opera-
tions, read before the Philadelphia Medical Society in 1834. Cir-
cumstances rendered it difficult to accomplish this design, and it
was indefinitely postponed.
The object of the lecture was to show that the establishment of
the suppurative process at the orifice by which the bowel escapes
in hernia, would result in the formation of a barrier sufficiently
strong to resist permanently any propulsion of the viscera, and a
plan was proposed by which this process might be established with
comparatively little danger of inducing peritoneal inflammation.
Your own investigations and improvements have rendered the
plan proposed unnecessary, and, as it was in its nature not unat-
tended with danger,-improper. There remains, therefore, no ob-
ject in giving it publicity.
Incidentally, in the course of this lecture, I alluded to the cases
of radical cure resulting from sphacelation of strangulated omentum,
and accounted for the happy result of these cases by describing the
strong contractile power and solid nature of the bond of union
between suppurating surfaces.
When called in consultation in the case to which your note makes
reference, I stated my conviction that the bond just mentioned
would be found an efficient obstacle to the escape of the intestine,

APPENDIX.
177
nor have I changed that opinion in consequence of the exception
presented by that case.
But, in the application of the law, one thing is worth remem-
brance; namely, that considerable time is necessary to enable the
bond of union to contract and to assume the requisite solidity.
This time should be passed by the patient in a recumbent posture,
if no instrument be employed; but in Dr. BOND's case, the circum-
stances of the patient did not admit of this kind of security, and
the parts were necessarily subjected to the propulsive force of the
intestines, before the barrier had acquired sufficient firmness to
resist the unusual exertions which she was compelled to make in
ascending and descending the most inconvenient stair-case which I
ever saw.
I regret having expressed to Dr. BOND the unreserved opinion
that "from the condition of the parts, there must necessarily be a
radical cure without the application of a truss," an opinion given
without reference to the unusual labours which the woman was
called upon
to perform. The recurrence of this hernia has con-
vinced me, that under such circumstances, the application of a
truss until the parts have acquired due firmness is necessary, and
that, in all cases, it is a proper precaution.
Your question with regard to the instrument employed, is easily
answered. In form this bore more analogy to your Umbilical truss
than to that designed for femoral hernia, though it differed widely
from any of your instruments. The Committee having stated its
approval of the principle of action, and the mode of application of
your femoral truss, it is hardly necessary for me to express my
objections to one so different in character."
I have addressed you this hasty reply, as it will be impossible
for me to publish any remarks upon the subject.
Very truly, yours, Monos
REYNELL COATES.
HEBER CHASE, M. D.
September 4th, 1837.
22
di nisoisos olinde, miw bein
nebioos ad conte aysb ovl
Estions vd hobratts need
horstein

178
APPENDIX.
Having now completed the Reports of the Commit-
tee, together with the observations appended thereto,
and having also added such further notes on my own
authority as were thought necessary to elucidate some
additional facts in connexion with those cases, the fol-
lowing pages will contain the statement of a few cases
of peculiar interest which were never thrown before
the Committee.
The following cases will illustrate the correct mode
of treating omental hernia after sloughing has taken
place.
Mr., stone-mason, aged 20 years; Strangulated In-
guinal Omental Hernia, from lifting a heavy stone.
Sloughing of the omentum, and radical cure by the use
of the Inguinal truss.
CASE XXXII.-Dec. 29th, 1836.-I was requested
this day to visit the patient, whom I found labouring
under a strangulated omental hernia. The tumour
occupied the whole length of the inguinal canal, but
did not descend into the scrotum. This tumour ex-
hibited an inflammatory appearance, was hard to the
touch, giving pain on pressure, and had the peculiar
doughy feel which usually attends omental protrusion,
and some abdominal tenderness which was accompa-
nied with febrile action in the system. It had been about
five days since the accident happened; the patient had
been attended by another practitioner, who admi-
nistered laxative medicines, and had ordered eight

APPENDIX.
179
ounces of blood to be taken from the arm two days
previous. Taxis had also been employed, but to no
purpose.
Believing it yet possible to reduce the omentum, I
ordered leeches to the part, followed by saturnine
lotions, brisk cathartics, and rest.
30th.-Bowels freely opened; abdominal tenderness
removed; febrile excitement abated; inflammation and
tenderness of the tumour less, but the parts felt very
firm at the internal abdominal ring. I endeavoured to
reduce the tumour by taxis, but with no effect. Cold
applications were applied.
31st. The patient was bled again from the arm
3xiv. I instituted taxis; no relief was obtained there-
by. The tumour continued firm at the ring.
January 2nd, 1837.-Ceased all application.
3d.-A slight softening at the centre of the tumour
was observed. I ordered warm infusions.
4th.-Bread and milk poultices were applied.
9th. The bread and milk poultices having been
continued since the 4th, the tumour now fluctuates
quite freely.
11th. The tumour discharged itself by a small
aperture, which was enlarged by the lancet.

180
APPENDIX.
13th. The sphacelated portion of omentum was
removed, leaving a cavity.
14th.-Gradual pressure was applied.
17th.-An instrument with a very light spring was
adjusted.
23d. The patient was permitted to walk about
the room with the truss on.
30th. He was allowed to leave his room, and in a
few days he returned to his business, still wearing his
instrument by my orders.
Shortly after this, the young man left the city to
fulfil an engagement in the country, and I did not see
him again until
May 6th.-When I was requested to visit him at his
father's house, where he had been brought from the
country, having received a severe injury of the knee-
joint. He was not wearing the instrument.
10th.-I asked him when he threw aside his truss;
he replied, "a month ago." He also informed me that
he had never felt the smallest inconvenience from his
rupture since he had been permitted to leave his room.
After his recovery from the injury of his knee, he
returned to the quarry. I have seen him occasionally
since. He is radically cured.*
"As the operation for (strangulated hernia,) does not usually

APPENDIX.
181
Supposed Omental Hernia, of six days' standing, caused
by fast walking; age of patient about 21 years; cure
believed to be radical from absorption, and use of the
truss.
CASE XXXIII.-Miss
a highly respectable
young lady, aged about 21 years, had her attention
drawn to a pain and tumour in her right side, while
dressing for an evening party, April 19th, 1836.
This lady had walked, late in the afternoon of that
day, a mile in the city, to which she attributed her
rupture.
Has
prevent the parts from becoming protruded again, a truss must be
applied before the patient leaves his bed, and afterwards constantly
worn."-Mr. S. Cooper's Dic. Prac. Surg.
"The treatment of a patient who has undergone the operation
for
any form of strangulated. hernia, will materially influence the
final result. This operation does not, like some others, cure the
affection for which it was performed; it forms only a temporary
means of relief, to save life. When the protruded parts have been
returned, light dressings of compresses, retained by a bandage,
should be applied; the patient should be kept perfectly quiet, and
not allowed on any account to stir from his bed. His diet should
at first be very abstemious, and if the bowels be not opened within
five or six hours, a dose of castor oil, or some other mild laxative,
may be given, aided, if necessary, by enemata. If the symptoms
are very violent, and the pulse, &c. indicate the existence of in-
flammation, venesection, leeches and fomentations, may all be re-
sorted to. When the parts have completely united, and before the
patient rises, a truss should be applied, a neglect of which pre-
caution would almost certainly result in a second protrusion."-
Notes to Colles' Surg. Anat. by J. P. Hopkinson, M. D.

182
APPENDIX.
April 26th. I was requested to visit her by her
physician, who had been in daily attendance since the
accident happened. I found her confined to her bed,
and labouring under an omental hernia extending from
the internal ring two and a half inches toward the
pubes, and nearly of the size of a man's wrist, highly
inflamed, and very tender to the touch. The pulse
was excited, and the patient had some fever. She had
suffered greatly from taxis, the only means of reduction
employed by her physician: this treatment had, at dif-
ferent times, produced symptoms of strangulation.-4
o'clock, P. M. I ordered v. s. 3x., laxative medicines,
cold applications to the tumour, and perfect rest.—8,
P. M. Pulse reduced; fever diminished; two dis-
charges from the bowels were obtained; the pain and
soreness in the tumour still continue. Ordered vii.
of blood from the part by leeches, the bleeding to be
encouraged by warm applications.
27th.-9, A. M. The tumour diminished in size,
pain and soreness.
28th.-Patient comfortable.
Careful efforts were
now made to reduce the omentum, but without success.
Pain again produced by taxis. Ordered lead water to
be applied.
29th. The limb being flexed in the proper position,
a second attempt was made to reduce the tumour, but
no relief was effected. That portion of the tumour
which is over the site of the internal ring was now

APPENDIX.
183
observed to be firmer than other parts. 3vi. of blood
were ordered to be taken from this point, by leeches.
May 1st.-The firmness at the internal ring continues.
2nd.-Poultice ordered to the part.
5th. The patient now experiences no unpleasant
symptoms whatever. The tumour is firm at the inter-
nal ring as before, but is diminished in size; it is soft
and elastic throughout the remaining portions. The
bowels have been kept freely open.
10th. The tumour has declined to half its original
size since the last date. Ordered all local applications
to be removed, and one ounce of Epsom salts to be
administered.
12th.-I found the patient still in bed. I applied
pressure by means of compress and roller.
15th.-Patient rose and walked the room with com-
parative ease.
18th.-Removed the bandage and applied an instru-
ment, the tumour having quite disappeared, except a
slight thickening at the internal ring.
20th.-Truss worn without inconvenience.
30th.-Saw Miss; she had been in the country;

184
APPENDIX.
returned to-day, and now feels none of the effects of
her former malady.
July 20th.-Miss - continues well.
January 2nd, 1837.-I ordered the instrument to be
finally removed.
August 10th.-This young lady has now left the city
for the west, apparently free from hernia.
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ON DISEASES MISTAKEN FOR HERNIA.
lowou
185
2014
In my Treatise on the Radical Cure of Hernia, pub-
lished in 1836, p. 185, I entered at some length on
"Diseases Mistaken for Hernia." My views, as set
forth there, have since been most fully sustained. It
is not my intention to enter into a full account of those
diseases and their treatment, that task being reserved
for a future occasion, but it may be proper merely to
call the attention of the reader to some cases which
have recently fallen under my observation.
oney yout duit ga
Among those most commonly met with, are: Vari-
cocele, or a varicose state of the veins of the cord.
Buboes, or glandular swellings in the groin from any
cause. Hydrocele, or dropsy of the tunica vaginalis.
Hydrocele of the Cord. Enlargement of the Cord from
any cause, and Fatty Tumours.
oda bos
Varicocele or Cirsocele. Prior to the year 1837, I had
been consulted in more than a dozen cases by persons
for relief in hernia, when, upon examination, I found
them labouring under varicocele, and frequently wear-
ing trusses applied by truss-makers and druggists.
collo Austus 20000
23

186
APPENDIX.
Patients of this description are still constantly falling
under my observation. It has heretofore been almost
universally the custom for practitioners to send their
patients to instrument-makers for trusses, and it is by
no means uncommon to hear some of these gentlemen
boast of the number of trusses they have "put on."
Should they be able to distinguish an enlarged vein, a
firm tumour, or a bag of water, from a bowel, the know-
ledge appears of little moment to them, provided they
effect their object, the sale of a truss, even at the risk
of the health or life of the patient.
It is not altogether without precedent even at the
present day, for surgical authors to censure the pro-
fession for mistaking varicocele for hernia; and there
can be no doubt that such mistakes may sometimes
happen even amongst the "Fathers of the Medical
profession;" but it may safely be said that in those
cases where trusses are thus improperly employed,
there is seldom ground for believing that they were
applied by those whose extent of surgical knowledge
and acumen have equalled their desire for such ac-
quirements.
That these mistakes should occur is not to be re-
garded as at all surprising, when men who have
laboured hard and long in the profession, and who
have taught and written much for the benefit of their
younger brethren, are found to employ the following
language in opposition to that of men of perhaps
equal experience, such as Sir Astley Cooper, Law-
rence, Sir Charles Bell, Tavernier, Dorsey, Gibson,
Mr. S. Cooper, Warren, Colles, &c. &c.

APPENDIX.
187
"Various instruments of this description (trusses)
are before the public. Each must finally stand on its
own merits. It is also worthy of remark, that surgeons
are far from being the sole umpires on this subject.
Hernia is a very common disease, and a numerous
body of persons have had ample experience in the use
of the truss. Many of these individuals are men of
intelligence and reflection, who feel themselves qualified
to form a judgment of their own. Hence public opinion
will materially regulate this subject, independently of
the medical profession."-Parrish's Surg. Observations,
P. 4.*
*"No disease of the human body, belonging to the province of the
surgeon, requires in its treatment a greater combination of accurate
anatomical knowledge with surgical skill, than hernia in all its
varieties."-Sir Astley Cooper.
"It can hardly be necessary to say, that the surgeon should be
careful to see that the truss fits, as his success and reputation de-
pend on such care. A truss which does ns. press enough is worse
than none at all, as it occasions loss of time, and deceives the pa-
tient or his friends; and one which presses too much, or on an im-
proper part, gives pain and trouble, by producing an inflammation
and swelling of the spermatic cord, and sometimes of the testicle."
-Lawrence.
"When the hernia is reduced, we still feel the empty sac; and
now the surgeon must be particularly careful that no portion of the
gut or of the omentum remains in the neck of the sac, when he is
about to apply his compress or truss; for high inflammation, or all
the effects of strangulation, may result from this."-Sir Charles
Bell.Show Droga Bol
"Too much attention can never be paid to the application of a
herniary truss; because it is upon the manner in which it is adjusted,
that depends not only the cure of the hernia, which may often be
effected in young subjects, but also, we may say, the life of the
patient. A truss, when badly applied, is worse than useless, and
will always have a tendency to produce mischief."-Tavernier.

188
APPENDIX.
GLANDULAR SWELLINGS IN THE GROIN.
the oillig, odt blod one
Tumour in the Groin mistaken for Hernia; age of patient
6 years; application of poultice to the part; discharge
of contents; cured.
ser of
alecan
190 to vhod
CASE XXXIV.-April 24th, 1837.-A lady called at
my office accompanied by her little son, aged 6 years,
"The large proportion of mankind who are afflicted with this
complaint; the great variety of forms in which it appears;-the fa-
tality which results from its improper treatment, and the ample
resources of surgery in preventing its evil consequences, are cir-
cumstances which combine to render the investigation of hernia
peculiarly interesting."-Dorsey.
"To accomplish this purpose, (the cure of hernia,) great attention
must be paid by the surgeon in adapting the instrument to the parts,
and by the patient in wearing it without intermission."-Gibson.
"The first applications of a truss should always be made under
the superintendence of the surgeon himself; and care should be
taken to put on the instrument in such a manner that the lower third
of the pad will compress the neck of the hernial sac against the os
pubis, while the upper portion will compress the abdominal ring.
The surgeon should also make the patient acquainted with the right
manner of applying the truss, the principles on which it keeps up
the bowels, and affords a chance of a radical cure."-Mr. S.
Cooper.
orbes et elend of
"If this particular period (time of applying trusses) should be
more carefully observed by surgeons, and the application of the
truss, instead of being abandoned to mechanics, receive a greater
share of their attention, they might be instrumental in obviating
much of the distress which has been entailed upon the world."—
Hooper's Med. Dic., Article Truss.
"These symptoms (of varicocele) lead patients and ignorant truss-
makers to consider the disease hernia, apply a truss, and thus ag-
gravate the disease."-Warren's Surgical Observations on Tu-
Capsite
erad sawls liv
mours.

APPENDIX.
189
whom I had cured of an inguinal hernia of the right
side. She informed me that she thought "the disease
had returned." Upon examination I found a tumour
of about the size of a hen's egg, located near the seat
of the internal ring, but a little outward and upward
therefrom; and upon further examination, I was con-
vinced that it was not a return of the bowel. The
mother fearing there might still be something wrong
in the case, I requested Dr. R. COATES to see the pa-
tient, who coincided with me in opinion. I ordered
the parts to be poulticed. In five days the abscess
opened spontaneously: the contents were discharged,
leaving a smooth cavity, the edges of which were
drawn together by adhesive strips, and in ten days the
patient was well.
Not unfrequently, fatty tumours are found to occupy
the seat of crural hernia, which should not be mistaken
for this disease. od wol a trailer
both inabing out tud Asiles
"From the course in which the spermatic cord is seen to run
down along the fore part of the pubes, you may infer that, in the
old manner of applying the pad of the truss upon the external ring,
there was some danger that the cord would be compressed between
the instrument and the bone. The pain caused by this, you must
suppose, would be very great, and yet it has been submitted to, by
some patients, for a length of time, at least sufficient to produce
serious diseases of the cord or testicle."
100
Again, as the chance of curing hernia by wearing a truss de-
pends on our being able to close up, or restore to its natural state,
that opening at which the bowel protrudes, it is obvious, that the
instrument should be made to press on this point, or on the internal
abdominal ring; for pressure applied to any part below this, leaves
the mouth of the sac open, and ready to receive the viscera on any
future exertion."-Colles' Surg. Anatomy.
66
motor u alle

190
APPENDIX.
Femoral Hernia mistaken for an inguinal gland; age of
patient about 45 years; operation for strangulated her-
nia; death of the patient.
bedd
CASE XXXV.-A few months ago I was requested
to visit a public institution near this city, to apply a
truss in a case of hernia. On examination, I found the
patient labouring under irreducible femoral hernia.
The tumour was of the size of a filbert, and could not
be returned into the abdomen. The surgeon and at-
tending physician of the house thought the existing
tumour to be a lymphatic gland; that the bowel had
been returned, and wished the instrument to be applied.
Satisfied that such was not the case, I refused to com-
ply with their request.
On the third day following, the symptoms of stran-
gulation came on: an operation was performed for his
relief, but the patient died a few hours after.*
Hydrocele, or Dropsy of the Tunica Vaginalis.
CASE XXXVI. In the early part of the year 1837,
enorden of
* This species of hernia is liable to strangulation, even before it
can be felt externally. Hence it is obvious, that we must establish
our diagnosis principally on the preceding and concomitant symp-
toms of the case. Some fatal effects have resulted from mistaking
strangulated crural hernia for inflammation of some of those
lymphatic glands which lie in the vicinity of the crural ring. The
deep situation of the hernia, together with its very small size, have
contributed to render the mistake more frequent. In some instances
the difficulty of discriminating is considerably increased by an en-
larged lymphatic gland lying anterior to a very small hernia.-
Colles' Surg. Anatomy.

APPENDIX.
191
I was called to visit the son of a clergyman of this
city, who was supposed to be labouring under double
inguinal hernia. He was wearing a single truss. On
examination, I found that whatever might have been
his former condition, he had at this time, no protrusion
of the bowel; but he was labouring under hydrocele
on both sides, which, by a superficial observer, might
be mistaken for ruptures.
This watery effusion could be readily returned into
the abdomen, showing that the necks of the sacks were
not closed. Upon further examination, I found a gene-
ral dropsy of the system, and that the patient had
laboured, not long before, under an attack of scarlatina,
the dropsy being one of the sequelae of this disease.
I requested that the family physician might be called
in attendance, which was done. The patient died,
however, of hydrothorax, in a few days.
Hydrocele of the Cord.
CASE XXXVII.-On the 11th of August, 1837, a
gentleman and his wife, from the interior of this state,
called on me (by the advice of their physician,) with
their little son aged three years, to consult me in rela-
tion to an inguinal rupture, to which it was supposed
their child had become recently subject.
After a careful examination, I found the disease to
be dropsy of the cord. The fluid could not be returned
within the ring; but the tumour presented at all times
the appearance of a hernia. Under appropriate mild

192
APPENDIX.
treatment, the affection disappeared in about a week.
As the physician whose patient the child had been,
thought there was at times a protrusion of the bowel,
I furnished the parents with an instrument to be em-
ployed in case the bowel made its appearance, but under
no other circumstances. The
The parents returned home
with the child, and I have heard nothing further of the
case. Dr. WARREN of New Orleans, has met with two
similar cases.*
noisy aid
OTO adora o Enlargement of the Cord.
Perron's basel Io
tout
CASE XXXVIII.-August 10th, 1837.-I was re-
quested to see Master- , aged five years, who
had an inguinal hernia, which had passed only into
the upper portion of the inguinal canal.
This was
easily reduced, leaving a tumour which resembled
a bowel, and, on examination, was found to be at-
* From the connexion which' inguinal hernia has with the sper-
matic cord, you must expect that those diseases to which the cord
is subject, will bear a resemblance, more or less strong, to this
form of hernia. Thus, when water collects in a cyst on that part
of the spermatic cord which lies in the inguinal canal, forming en-
cysted hydrocele of the cord, the appearance and feel of the parts
will not be such as to constitute a satisfactory distinction between
these diseases. We must then depend a good deal upon the his-
tory of their origin and growth, and also upon their attendant
symptoms.-Colles' Surg. Anatomy.
A sac of fluid formed upon the cord, or the cellular hydrocele
of the cord, may be mistaken for this kind of hernia. If large,
the tumour may be known from its transparency, its uniformity,
and elasticity; it does not receive the impulse from coughing, as the
hernia does.-Sir Charles Bell.
793 odi

APPENDIX.
193
tached to the whole length of the cord between the
external ring and the testicle. Strong efforts were
made to detach the tumour, but without effect. The
hernia being reduced, I applied the Inguinal truss,
which perfectly retained the bowel, the tumour remain-
ing in the same situation.
12th. I requested Dr. R. COATES to see this
patient. On examination his opinion corroborated my
own. We judged the tumour to result from a depo-
sition within the substance of the cord.
13th. The patient wears his truss without any in-
convenience.
17th. Since the application of the truss there ap-
pears to be an evident diminution of this tumour.
Sept. 15th.-—On a careful examination of this case
to-day, no appreciable difference could be observed
between the two cords by the eye; and a very slight
thickening could be felt between the testicle and ab-
dominal ring.
Ventro-inguinal Hernia, which had passed into the scro-
tum; occurred while fox-hunting; mistaken for Hy-
drocele; patient objected to the operation for Hydrocele.
or paillee
CASE XXXIX.-January, 1836.-H— S―, an En-
glish gentleman now resident in Philadelphia, has been
subject to ventro-inguinal hernia of the left side for
ten years. This accident occurred in fox-hunting.
24

194
APPENDIX.
This patient consulted Dr. HARTSHORNE, who re-
ferred him to me. The hernia was easily reduced, and
was perfectly retained by the ventro-inguinal truss.
He had never worn any instrument previous to this
application. The tumour always retired at night, and re-
appeared during the day. About five years ago he con-
sulted a Danish naval surgeon, then on the West India
station, and the case was pronounced hydrocele. Two
different hours were appointed on different days, for
the operation of tapping and stimulating injections;
but fortunately the fears of the patient in both instances
prevented the execution of the design! No attempt at
reduction had been made by the surgeon, as there was
not even a suspicion of hernia in the case; and the
diagnosis was thought to be so perfectly plain, that
great offence was taken at the unwillingness of the
patient to submit to advice! The reading of a medical
work at length convinced the gentleman that he la-
boured under hernia, which induced him to apply to
Dr. HARTSHORNE.-Chase on Hernia, p. 190.
Varicocele mistaken for Hernia; case of four years' stand-
ing; application of Dr. Hull's truss; afterward of Mr.
Stagner's instrument.
CASE XL.-A-Y-, Esq., a gentleman of high
standing, from one of the southern States, came to
Philadelphia for the purpose of consulting me relative
to a supposed "scrotal hernia," with which he had been
induced to believe himself affected.
About five years ago he consulted a gentleman, not

APPENDIX.
195
of the profession, who acted for the sale of a celebrated
truss invented in New York; who, under the belief that
the case was one of genuine hernia, applied the truss.
The patient continued to wear it for some time; but
finding the disease greatly aggravated under its use,
he at length relinquished it.
His disease still continuing, he applied for relief to
a gentleman in Washington, D. C., who furnished him
with Mr. Stagner's truss. This instrument he con-
tinued to wear for several months, until the distress
resulting from the complaint became altogether insup-
portable.
On examining the patient, I found that he laboured
under an unusually extensive enlargement of the veins
of the spermatic cord! He had cirsocele, and there
were no signs whatever that hernia had existed in the
case at any time!
Cbodies
This information being communicated to the patient,
his joy and gratitude were as great as could well be
imagined under such circumstances; for he had been
harassed and annoyed for years with even an exagge-
rated dread of strangulated hernia and the knife!*.
Op. cit. p. 178.
-
* I have more than once known a truss applied for this disease,
(varicocele,) and in one instance, to the son of a medical man, by
his father-Cooper's Lectures.

196
APPENDIX.
Inflamed Inguinal Gland mistaken for Hernia; age of
patient about 30 years; injury from the improper use of
a truss; Fistula; cure.
CASE XLI.-March 25th, 1837.-I was requested to
see Mr., from Virginia, a gentleman of a corpu-
lent habit, good constitution, and who had heretofore
enjoyed general good health. This gentleman's atten-
tion was first called to a tumour in the right groin,
near the seat of the internal ring, about two years ago,
when he consulted a physician, who applied one of Dr.
Hull's trusses. This instrument gave him no material
inconvenience. He wore it about two months, when,
the tumour not disappearing, he threw it aside. Shortly
after, he applied a second instrument, with a stronger
spring, but with no better success.
Soon after the trial of the last named truss, he met
with the instrument called Semple's truss, (the late
Dr. Hull's spring, with Price's leaden conoidal block.)
This truss is now in my possession: he wore it for a
few days with the leaden conoid placed directly on the
site of the internal ring, but was confined to his bed
by the pain produced by the instrument. His tumour
not disappearing, and his groin having received great
injury from the pressure, he threw aside all trusses.
I found him able to walk about, but with his right
inguinal region very much swollen, of a bluish colour,
with two small suppurating orifices on a line with Pou-
part's ligament, and near the site of the internal ring.

APPENDIX.
197
I ordered a large poultice to the groin, and left him in
the recumbent position.
26th.-On the removal of the poultice to-day, two
more orifices were observed: one, above those before
mentioned, and about an inch nearer the anterior su-
perior spinous process of the ilium: the other was situ-
ated a few lines nearer the os pubis than those first
spoken of.
Had
A communication could be traced between the first
three mentioned, by which they were united from twelve
to eighteen lines below the surface.
The upper one communicated with still another ori-
fice further to the right, and at the outer side of the
thigh; while the lower one penetrated almost to the
angle of the pubic bone.
27th.-Dr. R. COATES was called in consultation.
Poultices were removed, but re-applied.
1. and bac
28th.-Poultices removed; matter of a greenish
colour escaped on pressure. Ordered injections of
sulphate of copper grs. xxx. to the ounce of water; en-
joined rest in the recumbent position.
30th. The poultice re-applied.
#foot
April 1st.-Professor GIBSON met us in consultation
this day. On the removal of the poultice, a fifth abscess
was discovered situated a little below that last men-

198
APPENDIX.
tioned, extending down the thigh the distance of four
inches. Injections were also thrown into this exten-
sive opening.
Lavorser oft
It was suggested that a seaton should be introduced
from the upper orifice to that next adjoining, and that
the remaining fistulous communications should be treat-
ed by the injection of sulphate of copper, reduced one
half in strength.
2nd.-Professor HORNER met me in consultation this
day. I now applied graduated pressure over the ab-
scesses indiscriminately by means of cloth of elastic
webbing and compresses; attention was also paid to
his diet, which was ordered to be mild and nutritious.
Two grains of blue pill were directed to be taken every
night, and mild laxative medicines, when required.
Cold applications to the parts were also occasionally
employed when the heat of the parts was increased.
12th.-Upon examination it was found that the ab-
scesses were closing at the bottom; treatment con-
tinued.
15th.-No material change having taken place where
the seaton was employed, it was removed, and the in-
jection of sulphate of copper substituted.
20th. No material change.
Come farl Jodi wood stuit a betemig besevoodb

APPENDIX.
199
25th. The abscess, where the seaton was employed,
is now uniting under the use of the copper.
29th. The part of the abscess extending towards
the os pubis is now perfectly closed.
May 9th.-The abscess which passed down the
thigh is completely healed: the other fistula admitting
a probe to the depth of two or three lines only.
do not
18th.-Fistulæ entirely closed; patient permitted to
rise and walk about the room.
20th.-Patient rode out for the first time.
25th.-Compresses removed.
30th.-Mr. left the city for Virginia.
We saw no indication that hernia had ever existed
in this case.
lowed
Varicocele mistaken for Hernia, after cure of Hernia;
age of patient 28 years; test of cure, two and a half
years discontinuance of the instrument.
CASE XLII.-Common inguinal hernia of the right
side. Mr., a gentleman aged 28 years, accus-
tomed to much exercise. Accident of more than two
years' standing. The patient had never worn a truss
before he placed himself under my care.

200
APPENDIX.
In January 1835, my common Inguinal truss was
first applied. I saw the patient frequently for the two
first months; after which, he regulated the instrument
for himself. He continued the use of the truss two
months longer, and then relinquished it without my
advice.
June 10th.-I saw the patient again. There had
been no protrusion in the interval, but he complained
of slight pain and a sensation of weakness in the part,
when he rode on horseback, or was driven rapidly over
the pavement in a carriage.
May 20th, 1836.-The patient came to me stating
that he believed there was a relapse of the disease, and
that the bowel was in the scrotum. I examined the
parts very carefully, and found the cure complete.
The rings were perfect, but he had laboured under a
slight cirsocele on the right side, which had been con-
siderably aggravated by active exercise and the heat
of the weather.
July 20th.--The patient continues well of the her-
nia, and the cirsocele has been diminished under the
usual treatment. He has never been examined by
any other surgeon, having steadily refused to submit
to such an exposure.-Op. cit.
p. 176.
0
robny. Hosaid bogsta od

Cole. Med
APPENDIX.
ON THE DELAYED DESCENT OF THE TESTICLE.
201
ibly. Asso'n
The retention of the testicle in the abdominal cavity
for a time after birth, is not a very unfrequent occur-
rence: its passage downward into the scrotum may
take place at any subsequent period, and is usually
followed by the descent of the bowel, (enterocele.) I
have never seen a protrusion of omentum under these
circumstances.
Delayed descent of the Testicle for 18 years; age of patient
20 years; Inguinal Hernia of two years' standing;
Testicle brought down into the scrotum; bowel restored,
and truss applied.
CASE XLIII.-Mr. aged 20 years, of a re-
markably robust constitution, but of sedentary habits,
(a cordwainer by occupation,) consulted me relative
to his rupture. On examination, I found the testicle
in the canal. I introduced the index finger, carrying
it around and above this organ, and brought it down
into the scrotum, without material pain to the patient.
On the removal of the finger the bowel immediately
followed, but was readily restored to its proper situa-
tion. In the application of the truss, no pain or un-
usual inconvenience was felt by the patient. The
bowel was perfectly retained, while the testicle was
resting in the scrotum. This patient informed me, that
prior to his placing himself under my care, the bowel
sometimes descended, sometimes the testicle, and not
unfrequently both appeared at the same time. In the
last case the testicle usually appeared first, the bowel
25

202
APPENDIX.
following; and, pressing upon it, gave him great pain,
which resulted, no doubt, from the extreme tenderness
of the organ under such circumstances.
Late descent of the Testicle; age of the patient 22 years;
subject to Hernia for several years; Testicle in the scro-
tum; employed a truss with the Testicle put up into the
belly for one year; wore another instrument with the
Testicle in the scrotum one year; afterward the Testicle
was replaced in the belly and a similar truss continued
for a year; Chase's Ventro-inguinal truss applied after
the Testicle was brought down into the scrotum, and the
bowel reduced; cure of the Hernia believed to be radical.
CASE XLIV.-August 27th, 1837.-Mr. —, aged
22 years, of delicate health and feeble constitution,
consulted me this day.
This gentleman has been subject to inguinal hernia
for several years, accompanied with a descent of the
testicle. He states that about four years ago he con-
sulted a surgeon of New York, who recommended
Glover's truss, and directed that the testicle should
remain in the scrotum. On applying for the truss, the
inventor assured him that the testicle should be returned
into the belly with the bowel, and the truss then put on.
* "The testicle, involved in the contents of the hernia, cannot
be clearly distinguished. This species of hernia is particularly
liable to be mistaken for hydrocele, being sometimes combined with
a quantity of water, which, falling from the abdomen into the lower
part of the tumour, renders it transparent, and gives the idea of the
whole being a hydrocele."-Colles' Surg. Anatomy.

APPENDIX.
203
This was done; this instrument was worn for a year,
the patient receiving no other benefit from it than that
which resulted from the general retention of the bowel,
although, on any unusual effort, it would escape. He
now applied to Dr. Hull, who directed that the bowel
should be reduced, leaving the testicle in the scrotum.
This was accordingly done; Dr. Hull's truss, under his
(the late Dr. Hull's) direction, was worn for one year.
The patient had still no further prospect of relief. He
was then advised by Dr. Hull to have the testicle put
up into the cavity of the abdomen; to which opera-
tion the patient reluctantly consented.
A second instrument was now applied, which retain-
ed the bowel and testicle another year. At the ex-
piration of that time not finding his anticipations and
the assurances given him realized, he was induced to
abandon all instruments. From the continual protru-
sion which took place whenever he used unusual ex-
ertion, his hernia had at this time become nearly a
direct, or of the ventro-inguinal variety. As a dernier
resort, he addressed himself to Dr. GAGE, who applied
my Ventro-inguinal truss. The ring had become very
large, and the testicle could be passed up through it
with great ease. Before he applied the instrument, Dr.
GAGE placed the testicle in the scrotum; the truss gave
him no inconvenience, and he has continued under the
charge of Dr. G. up to this date.
The patient informs me that the bowel has never
since descended to his knowledge. He has worn the
truss constantly during the day, and generally at night,
following the direction of his surgeon.

204
APPENDIX.
Condition of the parts.-The external ring appears to
be located a few lines nearer the thigh than usual.
On reverting the scrotum, and carying up the finger
to the orifice, it is found contracted to the size of that
of the opposite side; resisting, but not appreciably
thickened, as has been observed in some cases in the
Report. Coughing, and other efforts, produce no
greater outward propulsion than what is felt when the
fingers are placed on the opposite side of the body.
There is an appreciable absorption of the adipose
matter beneath the skin. The skin appears in a slight
degree thinned, but no adhesion has taken place be-
tween it and the parts beneath.
Boilage
By placing the patient in a recumbent position when
the instrument was applied, raising the block from the
skin, and introducing the finger up to the ring, it was
observed that the centre of the block rested over the
orifice. On permitting the truss to resume its accus-
tomed position, the finger was forced by the block from
its situation, and the block assumed its natural rela-
tion to the parts.
In this manner it will be observed that the accurate
adaptation of an instrument can be ascertained with
facility.
The above case is truly interesting, and Dr. GAGE
has succeeded to admiration in the successful treat-
ment of it, agreeably to the definition of a radical cure
given by the Committee on Hernia.
fier

APPENDIX.
205
Hernia in a child one year old; no descent of the Testicle;
instrument applied.
CASE XLV.-May 18th, 1837.-I was consulted to
day by Dr. LEACH of Boston, respecting a hernia in a
child one year old. The protrusion of the bowel had
produced much annoyance to the little patient. The
testicle had not yet made its appearance; neither could
it be detected in the inguinal canal, nor at the ring.
Under these circumstances as there were no means of
calculating the precise time at which the testicle would
descend, and as the case was continually subject to
strangulation, I advised the application of an instru-
ment. The patient is still under treatment, and I am
not aware that any inconvenience has resulted from
the use of the truss.
Partial descent of the Testicle mistaken for Hernia; Testi-
cle yet in the canal; age of patient 35 years.
CASE XLVI. Mr., aged 35 years, of feeble
constitution and delicate health, consulted me on ac-
count of a difficulty which he supposed to be a rup-
ture. He had requested the advice of several medical
gentlemen, who had as often advised the use of trusses.
He had made several efforts to wear these instruments,
but always experienced so much pain and suffering,
that he was obliged to abandon them.
On examination, I found that the testicle had des-
cended into the canal, and was checked in its passage

206
APPENDIX.
to the scrotum, at the external ring, and rested just at
the edge of the pubic bone.
No instrument under these circumstances could be
tolerated, as they invariably caught the testicle between
the truss-pad and the pubic bone, or the tendon of the
abdominal muscles.
I assured him that it was the testicle and not a
bowel which gave rise to his suffering; and as the af-
fection gave him no inconvenience when the truss was
not applied, I advised him to discard all idea of using
an instrument.*
* There is no disease more difficult to be distinguished from her-
nia, than an inflamed state of the testicle, which, having passed
through the internal abdominal ring, remains covered by the ten-
don of the external abdominal muscle, not having descended so
low as to escape through the second ring. How closely this must
resemble a variety of inguinal hernia may be readily inferred; for
the situation of the tumour is precisely the same in both cases, and
the symptoms attending inflammation of the testicle, thus situated,
exactly correspond with those of strangulated inguinal hernia. To
these difficulties we must add, the surgeon is apt, at once, to set
down the case as incarcerated hernia, a complaint with which he is
familiar, and does not suspect the existence of a disease which
must be extremely rare.-Colles' Surgical Anatomy.
The testicle partially descended at a period of life later than
usual, may be mistaken for inguinal hernia: often a truss has been
applied in this case. I have seen the operation for bubonocele per-
formed for the tumour of the testicle. The scrotum being empty
of the testicle should put us sufficiently on our guard.-Sir
Charles Bell.
off ont
105 CID

APPENDIX.
207
Unusual reduction of the testicle into the belly; age of
patient 25 years; instrument applied; no inconvenience
followed.
CASE XLVII.-In the summer of 1835, while en-
gaged in the application of an instrument in a case of
ventro-inguinal hernia, of the left side, occurring in a
gentleman aged 25 years, he accidentally slipped the
testicle up through the external ring into the belly.
Every effort was made to bring it down, but without
success.
A few days after, I applied the instrument, which
gave no pain, nor has he ever suffered any incon-
venience from the newly acquired location for the tes-
ticle, or from the pressure of the instrument.
I shall here terminate my cases, having already
continued this republication of the Reports, by notes
and cases, far beyond my original intention. Many
cases of cures of hernia in adults, but more particu-
larly in children, could be added, as well as others of
interest, bearing upon this very interesting subject.
If the notes and additional cases appended to a
Report so perfect in itself, should be read with that in-
terest which the subject seems to demand, when so
great a portion of the human family are labouring
under this afflicting malady; and should the life of even
one of my fellow-creatures be saved, or his condition
ameliorated, then will my labour be fully repaid, and I
shall consider my compensation ample.

208
APPENDIX.
No.
Age in years.
Sex.
OCCUPATION.
1 27 M Merchant
28 mo M Child
3 25 M Planter
4 35 M Merchant
5
3 M Boy
6 80 F Lady
M Child
TABULAR STATEMENT OF 200 CASES OF HERNIA.
7
2
8 57 M Farmer
9 61 M Boatman
10 27 M Carpenter
112 mo F Child
12 60 M Merchant
13
3 M Child
14
2 F Child
15 27 M Medical student
16 25 M Bank
17 23 M Merchant
18 2 F Child
19 30 MU. S. Army
20 27 M Engineer
Congenital.
Inguinal.
Right side.
Left side.
V. Inguinal.
Right side.
Left side.
1
TT
1 1
1 1 1
1 1
TT
1 1
1 1 1
1 1
11 1
1 1
11
1 1 1
1 1
1
1
1
1
1
Femoral.
Right side.
Left side.
Umbilical.
Ventral.
Irreducible.
Double.
1 1
Duration in
years.
7
years
7 months
12 CC
66
18
12 years
60 66
4 months
8 years
2 66
Many
6 months
1
year
18 years
10 days
Unknown.
Unknown.
Fox chase.
Unknown.
Unknown.
Unknown.
CAUSES, &c.
Fall down stairs.
Lifting.
Unknown.
Unknown.
Costiveness.
Coughing.
Unknown.
Dysentery.
Unknown.
110 years
15 days Unknown.
18 months Whooping cough.
8 years
Unknown.
Leaping from cars.
66

APPENDIX.
209
21| 22 |M|Carpenter
22 35 M Sailor
23 65 M Merchant
24 34 M Shoemaker
25 33 F Lady
26 28 F Market-woman
27 48 M Weaver
28 6 M Child
29 60 M Gentleman
30 26 M Clerk
31 39 M Engraver
32 57 F Lady
33 30 F Lady
34 25 M Iron founder.
35 50 F Lady
36 1 M Child
37 21 M Miller
38 2 mo M Child
39 49 M Physician
40 19 M Farmer
41 36 M Merchant
42 41 MArtist
43 45 M Shoemaker
44 37 V Clergyman
45 5 M
46 23 M Segar maker
47 47 M Taverner
48 45 M Gentleman
1
1 1
1 1
1 1 1
1 1
1 1
1 1
1
1
1 1 1
1
1 1
1 1
1 1
1 1 1
1 1
1 1
11
1
1 1 1
1 1
1 1
1 1
1
11
1
1
3 years
1 month
3 days
10
20 years
10
66
Many
5 days
20 years
Many
15 years
20 66
7 66
1 Many
2 years
6 months
2 years
20 years
3
66
3
14
5
3
66
6 months
35
Unknown.
Lifting.
Unknown.
66 Unknown.
66
Lifting.
Unknown.
Unknown.OPER
Unknown.
Unknown,
Unknown.
Unknown.
Fall.
Unknown.
3 years
3 months
Unknown.
Childbed.
Childbed.
Unknown.
Colic.
Carrying.
Lifting.
Unknown.
Speaking.
Unknown.
Lifting 500 lbs. of tobacco.
Unknown.
Lifting.

210
APPENDIX.
No.
Age in years.
Sex.
OCCUPATION.
35 M Tallow chandler
49
50 3 M Child
51 39 M Quarrier
52 45 M Taverner
53 28 M Farmer
54 20 MPainter
55 39 MEngineer
56 27 F Washerwoman
57 3 mo M Boy
58 37 M Sea captain
59 62 M Tanner
60
61 6 F Girl
7 M Boy
62 30 M Broker
63 28 M Merchant
64 18 M Collegian
65 47 M Pres't of Bank
66 18 M Shoemaker
67 31 F Housekeeper
68 36 F Domestic
69 41 M Boatman
Congenital.
Inguinal.
Right side.
Left side.
V. Inguinal.
Right side.
Left side.
1 1
1
1
1 1
1
1 1
1 1 1
1 1
1 1
1 1
1
1 1
1 1
1
1 1
1 1
1 1 1
1
1
1 1
1
Femoral.
Right side.
Left side.
Umbilical.
Ventral.
1 1
1 1
1
Irreducible.
Double.
1
8 days
115 years
1 year
Many
7 years
15 CC
17
Duration in
years.
77212
1 month
15 years
CC
1212
18
10
CC
66
66
66
66
66
66
CAUSES, &c.
Fell backwards on the ice.
Unknown.
Riding on horseback.
Lifting.
Washing.
Unknown.
Kick of a horse on the side.
Unknown.
Unknown.
Unknown.
Unknown.
Riding on horseback."
Unknown.
Lifting a stone.
Lifting.
Jumping into boat from the canal.

APPENDIX.
211
70 38 MOrgan builder
71 60 M Farmer
72 65 M Servant
73 43 M Tanner
746 mo M Child
75 37 F Boarding house
76 20 M Carpenter
77 24 M Merchant
78 25 M Mason
79 19 F Lady
80 35 M Victualler
81 32 MMerchant
82 31 M Lawyer
83 28 M Watchman
84 61 M Gentleman
85 30 M Merchant
86 35 M Carpenter
87 32 M Porter
88 45 F Nurse
89 10 mM Child
90 70 M Turner
91 20 M Farmer
92 49 M Surveyor
93 60 MPauper
94 45 M Collier
95 39 MManufacturer
96 3 M Boy
97 18 F Lady
1 1
MHT
1 1
1 1
1 1 1
11
1 1
11
1 1
1 1
1 1
1 1
1 1
1 1
11
1
1 1 1
1
1 1
1 1 1
1 1
1
1
13 years
4
66
Many
2
66
2 months
2 years
13
66
4 66
Many
3
1 Many
1 R. S. 1 L.
66
16 years
4 66
1 Many
2 years
6
66
2 months
2 years
3 months
10 years
66
12
15 days
1 Many
3 years
3 months
2
years
Many
Plaining metal.
Hard labour.
Hard labour.
Raising hides in tannery.
Unknown.
Lifting.
Climbing trees.
Unknown.
Lifting.
Unknown.
Lifting.
5 Unknown.
Carrying a bag of grain up stairs.
Blow over the head with door bar.
Unknown.
Unknown.
Lifting a trunk over his head.
Unknown.
Fell on the rocker of the cradle..
Lifting bag of oats.
Loading manure.
Surveying in the forests
Unknown.
Hard labour.
Unknown.
Fall.
Unknown.

212
APPENDIX.
No.
Age in years.
Sex.
OCCUPATION.
98 56 M Shoemaker
99 47 M Iron merchant
100 20 M Medical student
101 21 M Groom
102 13 M Boy
103 27 F Lady
104 60 M Army
105 35 M Merchant
106 40 M Sea captain
107 50 M Gentleman
108 55 M Merchant
109 42 M Sailor
110 28 F Lady
111 6 M Child
112 30 M Carpenter
113 2 M Child
114 45 M Mason
115 35 M Sailor
116 22 M Inn-keeper.
117 9 M Child
118 45 M Cooper
Congenital.
Inguinal.
Right side.
Left side.
V. Inguinal.
Right side.
Left side.
1 1
1 1
1
2 1 1
1 1 1
21 1
1 1
1 1
1
1
1
1
1 1
1
1
1
1
1
Femoral.
Right side.
Left side.
1 1
1
1
Umbilical.
Ventral.
Irreducible.
Double.
1
Duration in
years.
2 years
5 days
10 years
5
cc
7
2
CC
CC
Many
5 years
110
CC
1 Many
'
10 years
CC
2
1 Many
4 years
Many
CAUSES, &c.
Lifting.
Lifting iron.
At play.
Unknown.
A fall.
Unknown.-Unmarried.
Unknown.
Running after an omnibus.
Unknown.
Unknown.
Unknown.
Unknown.
Unknown.-Married.
pa
Unknown.
Unknown.
A blow on the inguinal region.
6 months Unknown.
Unknown Unknown.
Many Unknown.

APPENDIX.
213
119 60 M Inn-keeper
120 25 M Farmer
121 11 M Boy
122 27 M Forger
123 30 M Teacher
124 40 M Broker
125 8 M Boy
126 27 M Ostler
127 29 M Merchant
128 39 M Labourer
129 79 M Tinman
130 27 M Church
131 31 M Carpenter
132 27 F Nurse
133 45 M Lawyer
134 18 M Tinman
135 20 M Trunk-maker
136 45 M Farmer
137 18 M Mason
138 35 F Lady
139 57 M Gentleman
140 45 M Dissector
141 25 M Jeweller
142 45 M Sailor
143 10 M Factory lad
144 38 M Sailor
145 18 M Hatter
146 20 M Mason
1 1
1 1 1
1
1
1
1 1
1 1
1 1
1 1
1 1
1 1
1
1
1
1
1 1
1
1 1
1 1
1 1
1 1
1
1
1 1
1
1 1
1
1
1 1
1 1
1 1
21 1
1 1
1
1
1
1
Many
16 years
10 CC
2 months
15 years
10 6C
1 Many
Many
8 years
Many
Many
1 year
Many
12 years
6 months
2 months
2 years
Many
Many
110 years
2
66
Many
2 years
8 months
66
14
Lifting.
Unknown.
Leaping from a window.
Unknown.
Unknown.
Unknown.
Unknown.
Unknown.
Unknown.
Shutting a window.
Unknown.
Lifting.
Unknown.
Unknown.
Unknown.
Lifting.
Carrying grain on the shoulder.
Leaping.
Childbirth.
Unknown.
Right, from jumping; left, lifting.
Drawing on boots.
Raising stones.
Unknown.
Carrying 200 weight up stairs.
Right, wheeling; left, unknown.

214
APPENDIX.
No.
Age in years.
Sex.
OCCUPATION.
147 2 F Child
148 35 F Lady
149 56 M Navy
150 50 M Lawyer
151 65 M Farmer
152 36 M Medicine
153 20 F Lady
154 30 M Miller
155 25 F Lady
156 30 MArmy
157 25 M Sea captain
158 12 M Boy
159 18 M Bar-keeper
160 18 M Merchant
161 1 F Child
162 2 Child
163 30 M Brick-maker
164 55 M Medicine
165 32 M Merchant
166 23 MOstler
Congenital.
Inguinal.
Right side.
Left side.
V. Inguinal.
Right side.
Left side.
1 1
1
21 1
1
1
1
1 11
1 1
1
12
1 1
1 Q
1
11
1
1 1
Femoral.
Right side.
Left side.
Umbilical.
Ventral.
Irreducible.
Double.
21 1
1
1
Duration in
years.
6 months
10 years
120
CC
25
ઃઃ
12 66
8 66
10 days
2 years
18 and 2
110 years
6 CC
2
66
9 months
19
4
66
10 66
66
39
6
115 years
1 year
66
CAUSES, &c.
Unknown.
Childbed.
Ventro-inguinal, from walking
-Umbilical, unknown.
Riding on horseback.
Thrashing grain.
Dysentery.
Walking-Unknown.-Unm'd.
Unknown.
Unknown.-Unmarried.
Thrown from a mule.
Unknown.
Fall from a tree.
Unknown.
Lifting packages.
Crying.
Unknown.
Laborious exercise.
Fox-chase.
Unknown.
Unknown.

APPENDIX.
215
167 35 M Artist
168 12 M Boy
169 22 F Lady
170 23 M Gentleman
171 45 M Medicine
172 26 M Clerk
173 57 M Planter
174 30 F Lady
175 85 M Gentleman
176 25 M Merchant
177 1 M Child
178 25 F Confectioner
179 55 M Farmer
180 50 M Innkeeper
181 45 M Bookseller
182 58 M Cook
183 62 M Carpenter
184 68 M Farmer
185 25 M Merchant
186 62 M
187 28 F Seamstress
188 60 M Merchant
189 42 M Soldier
190 27 F Lady
191 27 M Merchant
1927 mM Child
21 1
1 1
1 1
1
1
1 1
1
11
1
1
1
1
1
1 1
1 1
2 1 1
1 1
QQ
1
1 1
1
1
2 1 1
1
1
1
1
1/10 years
6
66
12
1
TT
1
2232
66
66
66
66
Co
Many
66
66
3 months
12 years
120 & 5 m.
6 years
4
66
12 66
10 CC
1 year
6 years
14 66
4
66
15
1 year
12 & 5 m.
6 years
66
Unknown.
Fall astride a billet of wood.
Unknown.
Unknown.
Straining at stool.
Lifting heavy boxes.
Unknown.
Unknown.-Unmarried.
Unknown.
Unknown.
Appeared in the bath.
Over-exertion.-Married.
3400
Over-exertion.
Springing suddenly out of bed.
Unknown.
Lifting.
Coughing.
Debility after long confinement.
Hernia followed descent of the
testis, which took place at 19.
A fall-patient weighs 300 lbs.
Unknown.-Unmarried.
Unknown.
Patient sunk under heavy weight.
S Inguinal,over-exertion-femo-
ral, reaching up.-Married.
Arranging goods on high shelves.

216
APPENDIX.
No.
Age in years.
Sex.
OCCUPATION.
193 50 M Carpenter
194 37 M Merchant
195 27 M Innkeeper
196 27 M Clerk
197 45 M Farmer
198 60 M Gentleman
199 55 M Mason
200 42 M Carpenter
Totals,
Congenital.
Inguinal.
Right side.
Left side.
V. Inguinal.
Right side.
Left side.
Femoral.
Right side.
Left side.
1 1
1 1
1
2 1 1
1
1
11
1
1
21 1
Umbilical.
Ventral.
Irreducible.
Double.
Duration in
years.
8 years
14
15
6
10
39
CC
66
ઃઃ
Many
120 years
110 CC
CAUSES, &c.
Hard labour.
Leaping a brook.
Lifting trunks.
Unknown.
Lifting heavy weights.
Unknown.
Hard labour.
Heavy lifting.
15 86 64 30 104 63 50 17 7 10 13 1 138
The following conclusions are deduced from the summary of the preceding Table.
Of 200 cases of rupture, 37 were double.
Of 37 cases of double rupture, 13 were ventro-inguinal on both sides-13 were common inguinal on both sides-2 were
femoral on both sides-1 was ventro-inguinal and femoral on the same side-2 were inguinal on one side and femoral on the other
-2 were ventro-inguinal on one side and umbilical, and 4 were common inguinal on one side and ventro-inguinal on the other.
Of 237 ruptures, 15 were congenital-86 common inguinal-104 ventro-inguinal-17 femoral-13 umbilical-1 ventral, and
1 irreducible.
Those cases of hernia where the bowel penetrated directly through the tendon at the external ring, and those also where the
bowel appeared first at the internal ring, and finally became direct or nearly so from its repeated protrusion and dilatation of the
orifice, are ranked under the head of ventro-inguinal hernia. The greater number of ventro-inguinal herniæ proves that the
ventro-inguinal truss is of more importance than either of the other instruments.

APPENDIX.
217
shale
woods boold od
ON CIRSOCELE OR VARICOCELE.
Varicose Veins.-By surgeons, the veins are termed
varicose when in a state of dilatation, attended with
an accumulation of dark-coloured blood within them,
the circulation of which is materially retarded in the
vessels affected by a variety of causes.
ceridence
This is a very common disease, and comparatively
few persons escape it during life. It occurs more fre-
quently in the young and vigorous. When veins are
brought into this state, they are not only really enlarg-
ed, but are to all appearance elongated; and in addition
to their irregularity, they exhibit a knotty, vermiform,
cord-like appearance, and a livid colour, coiling upon
themselves, and forming a considerable tumour.
Varices appear very frequently in the lower ex-
tremities, but are by no means confined to any one
part of the system. The testicle and the spermatic
veins are very susceptible of this form of disease.
When the disease is confined to the veins of the scro-
tum, it is called varicocele; but when it is extended to
the veins of the spermatic cord, it is then called cir-
socele.
ora ind eloooo1147
These two forms of disease are frequently spoken
of under the same head, (varicocele,) and, for all prac-
tical purposes, this may be sufficient.
Causes of Varicocele.-These are various-any thing
27
Lancial and

218
APPENDIX.
which prevents the return of the blood through the
spermatic veins to the heart, such as despondency,
warm weather, fatiguing walks, dancing, long stand-
ing, blows, sparring, lifting heavy weights, abuse of
the organs in early life, leaping, running, jumping,
and riding on horseback. Several of my patients
during powerful exertion have complained of feeling
something give way; pain followed, and, on examina-
tion, they found varicose tumours. It sometimes is
the consequence of other diseases of the neighbouring
parts, and I have not unfrequently seen it follow her-
nia humoralis.
956
ault clai¿doverd
Pressure upon the spermatic cord by a rupture, and
more particularly by that of an ill-contrived and worse
applied truss, is among the most frequent causes.
Almost all the old trusses, whatever may be the nature
of the rupture, press upon the external ring, and are,
by their inventors, directed to overlap the "cross bone"
(pubic bone). By this adjustment the cord is caught
directly between the instrument and the bone. It there
suffers compression, and a varicose state of the vessels
is almost universally produced to a greater or less ex-
tent. Notwithstanding the truth of the position here
taken, trusses have been constructed ostensibly to cure
varicocele, but they all act in the same manner as
those just described, and are only calculated to exag-
gerate, (which they most certainly do,) rather than to
relieve the complaint.*
Coung lead
Symptoms of the Varicose condition of the Testicle or
gard
* See Chase on Hernia, p. 187.

APPENDIX.
219
Cord. This affection occurs more frequently in tall
persons, and especially in warm weather. The first
indication that the patient usually experiences is a sense
of weight at the bottom of the scrotum, followed by a
gradual enlargement, and sometimes accompanied with
pain. This, however, is not invariably the case, for
we sometimes find the disease making its first appear-
ance at the abdominal ring; and under these circum-
stances it is often difficult to distinguish it from other
affections developing themselves at this point. The
sensation of heaviness increases; the scrotum becomes
elongated; the pain continues along the rout of the cord,
accompanied with increased warmth, till it reaches the
abdominal ring. The whole cord becomes also very
much enlarged; increasing while in an erect posture,
but decreasing when in a recumbent position; while in
the morning, if examined before rising, the disease will
scarcely be perceptible.
Should the affection in this state be suffered to make
unrestrained progress, the pain continues along the
canal, even into the abdomen and loins: pain in the
back is now produced, and also in the lower extremity
on the affected side, and a sensation of lassitude is felt
through the whole system.
Ene
The appearance of the testicle and cord has been
compared to a variety of objects, but more particularly
to a bundle of earth-worms. Varicocele, however,
under the eye of those who are at all conversant with
it, does not require the aid of these analogies to point
out its distinctions from other diseases affecting similar

220
APPENDIX.
parts; for cases of this complaint by no means exhibit
a uniform appearance, and those who are not familiar
with it should not undertake its treatment. In fact,
varicocele resembles nothing but varicocele.
Fokrege
This disease more frequently makes its appearance
during the summer months, and it frequently disappears
during cold weather.
A varicose tumour increases in size during the heat
of the day, and also after a hearty meal.
A young gentleman who was labouring under hernia
and varicocele, the latter disease being the result of
pressure of the bowel on the cord prior to the use of
a truss, called upon me on three successive days, after
hearty meals, thinking that the bowel had escaped from
beneath the truss. On examination, I found, on each
occasion, the varicose tumour enlarged; but it inva-
riably disappeared after a few hours, without requiring
the removal of the instrument.
The testicle itself is rarely involved directly in this
disease, yet it is not unfrequently the seat of severe
lancinating pains, followed by a wasting of the organ
and loss of its proper function. The disease is usually
confined to the left testicle or spermatic cord, though
not invariably, for sometimes it is seen on both sides,
and sometimes on the right side only.*
* The left side is supposed to be more frequently the seat of this
disease than the right, in consequence of the circuitous route which
the blood from the left testicle takes, in its return to the vena cava.

APPENDIX.
221
The nature of the Disease, and the indications in curing
it. I have already stated that the veins, when in a
varicose state, are enlarged, and apparently elongated;
they almost always retain their retractile power, so as
to resume their natural form and position when the
causes of the disease are removed, and the proper
treatment instituted.
O
The veins, like the arteries, are composed of three
coats, but differ somewhat from the last mentioned
vessels in their power of resistance. The external and
middle coat of the arteries are more resisting than the
corresponding coats of the veins, while the inner coat
of the latter exceeds greatly that of the former. The
middle coat is said to be sometimes found muscular.
The veins are not so elastic as the arteries, for when
left to themselves they collapse; but they possess elas-
ticity to a sufficient degree to aid materially in the
circulation of the venous blood: neither is there any
doubt of their spontaneous powers of contraction,
which may be shown, experimentally, in various ways.
Puncture one of the large veins, and the blood will be
seen to flow irregularly: apply cold to them, and you
readily diminish their volume: include a portion of a
venous trunk between two ligatures, puncture it, and
it will empty itself speedily and completely.*
out 10
* We have reason to believe that the veins are contractile; and
the possession of this property would be in accordance with their
fibrous character. Broussais affirms, that this action is one of the
principal causes of the return of the blood to the heart.
He con-
ceives, that the alternate movements of contraction and relaxation
are altogether similar to those of the heart."-Dunglison's Physi-
ology, p. 42.

222
APPENDIX.
Now, having given some idea of the nature of vari-
cocele, our next inquiry will be into the indications re-
quired to afford the most perfect relief, and, ultimate-
ly, cure the malady. In so doing, we have but three
points to discuss: 1stly, In what situation shall we
place the parts so as to secure their safe and easy
position, and give them the greatest chance of reco-
very? 2ndly, By what mechanical apparatus can they
be best retained in their position? 3dly, What other
than mechanical means can be employed to advantage
-the object being to place the parts in the situation
that will give the veins the greatest amount of aid in
dislodging their engorged blood, and allow them to
contract permanently to their natural situation?
In answer to the first of these positions-it is evident
that that position which will allow the veins to disgorge
themselves of blood most readily and effectually is the
best; and to effect this, they should be brought up and
retained in close contact with the perineum under the
root of the penis, so as to lessen, as much as possible,
the pressure of the column of blood.
HOT
Orod bloo vlaga sijalicant
The second question will be answered presently.
error
The third and last may find its reply in a short ac-
count of the various operations for the relief of vari-
cocele, and a notice of external application to be em-
ployed in the use of the following instrument.

APPENDIX.
223
fre
E
CHASE'S SUSPENSORY.
PUPLICURIINID DEVILY
SUITA
CHLEICH Y
A
ACI
B
ע.
A
B
ALEXER
E
THON-FOR
LUTHIERYTARE MADE
TURER
A
CTOR
bod
pirabe
gobro
fecr
odt
HT
Description of the New Suspensory Band.-A, A, A, A, The band or belt
of the suspensory, which passes around the body and is secured by a
buckle at D.
B, B, The sac to retain the testicles.
C, C, C, C, The thigh-straps, which are attached at one extremity to
the lower and posterior part of the sac at c c, pass beneath the sides
of the perineum and round the base of the buttocks, continue upward
on the outside of the nates, and behind the trochanter major, to be
attached to the band at E E by means of buttons.
D, The buckle of the band.
47 ono off
E, E, The situation of the buttons for the attachment of the thigh-straps.
H, H, H, H, India-rubber webbing introduced between the more un-
yielding parts of the suspensory belt.
I, I, I, I, India-rubber webbing constituting the middle part of the thigh-
straps.
ON THE USE OF THE PARTICULAR PARTS OF THE SUSPENSORY.
load bus ber
1st. Of the Bag.-This is the most essential part of
the instrument. It should be made of the most inelastic
material that can be obtained, (linen,) and should be
adapted as accurately as possible to the shape of the
OUGH 9900
en died od)
e) of
316

224
APPENDIX.
scrotum, when brought up into close contact with the
body.
2nd. Of the Belt.-That part of the belt which is
adapted to the front of the body, should be also com-
posed of linen; because, to this is secured the bag,
which requires to be attached to an inelastic tissue in
order to give firmness and certainty to its shape and
position. Linen should also compose those parts of
the belt which pass behind the spine and over the back
of the sacral bone.
The intervening parts of the belt marked H, H, H,
H, which correspond with the sides of the pelvis, are
made of India-rubber webbing. This arrangement
allows the belt to expand sufficiently to adapt itself to
the abdominal muscles in respiration, and relieves the
body from painful pressure.
No one who has worn a suspensory of old construc-
tion, need be reminded of the very great inconvenience
and annoyance which he has suffered from a non-elastic
bandage passing around the pelvis.
Of the thigh-straps.-These straps are intended to
keep the inferior and posterior parts of the sac drawn
upward and backward, so as to bring the whole scrotum
into close contact with the perineum.
Those parts of the thigh-straps which are attached
to the inferior part of the sac, and also the ends which
are secured to the belt, are made of linen, the inter-

APPENDIX.
225
vening portion being constructed of India-rubber, as
mentioned in the description of the figure.
Great annoyance is always felt from the thigh-straps,
which are entirely composed of non-elastic material.
It is ascertained to be requisite that the straps should
expand and retract sufficiently to adapt themselves to
the various motions and positions of the thighs.
On the manner of applying a Suspensory, and cautions
to be regarded. To give directions relative to the ap-
plication of an instrument apparently so simple in its
construction, may appear a work of supererogation to
those who look upon the subject theoretically; but to
those who have had occasion to treat a varicocele, or
who have laboured under the disease, no apology is
necessary for this minuteness. admit od:
if of: brid
The patient should be placed in the recumbent posi-
tion, which favours the return of the blood. The
scrotum should be raised and drawn forward by the
surgeon with one hand, and the remaining part of the
blood pressed from the spermatic veins into the abdo-
men by gentle friction with the fingers of the other
hand, performed along the route of the cord.
When this disease is of long standing, and the veins
have become greatly enlarged, the danger attending
the return of the blood to the circulation is imminent,
and should be performed with great caution. A case
occurred in the hands of Dr. R. COATES, in which the
patient was put in great danger of death for more than
28

226
APPENDIX.
an hour.
This patient has since placed himself under
my care.
He had suffered greatly from varicocele for
several years; had worn the old suspensories with little
if any relief, and in the days of castration would have
been considered a fit subject for the knife.*
The band of the suspensory should now be carried
around the body, drawn moderately straight, and se-
cured to the buckle; the penis passed through the ring,
and the testicles placed within the sac. The thigh-
straps are then brought around, and buttoned to the
belt as already described. The patient should now be
requested to rise; the different parts of the suspensory
band adjusted; the body-band tightened or loosened,
as occasion may require. The tension of the thigh-
straps also should be carefully regulated: they should
not bind the limbs, yet they should draw the lower and
posterior part of the sac far back upon the perineum.
The sac, which is by far the most important part of
the apparatus, should vary in size, but not in shape,
according to the size of the testicles in each individual.
It should be accurately fitted to the scrotum, and should
keep these organs closely in contact with that part of
the perineum just posterior to the penis.
grols Dormulsor dhund
* In the case of a young gentleman labouring under varicocele
recently under the care of Dr. R. COATES, the reduction of the blood
contained in the tumour was followed by symptoms so alarming,
that this surgeon considered the patient in imminent danger of
death for more than an hour. There were repeated attacks of pro-
found syncope, and occasional slight convulsions, which Dr. COATES
attributed to the action of coagula or hypercarbonated blood on
the heart and nervous system."-Chase on Hernia, p. 188.

APPENDIX.
227
By this arrangement the spermatic veins are enabled
to discharge themselves, and no blood is permitted to
collect or to be retarded in its circulation.
Directions for use. As before stated, this instrument
should be applied while the patient is in a recumbent
position, and it should not be removed except when he
is in this situation. It must be worn constantly until
relief or a cure be effected, as a deviation from these
rules would permit the testicles to fall, the blood to fill
the vessels again, and a return of the disease would
inevitably follow.
On the old Suspensories.-The old suspensories par-
take nearly of the same general form, and generally
fail to accomplish the very object for which they were
intended, viz: to support the testicles.
The surgeon who has had experience in the treat-
ment of varicocele, need not be reminded of the very
great mortification he has often felt after employing
one of these instruments to no effect, nor the patient
of the disappointment under which he has daily la-
boured, while expecting relief from their use.
The sac, which is intended to sustain the testicles, is
made of materials evidently calculated for distension,
which, when worn, permits the scrotum to fall almost
as low as it did prior to the treatment. Under these
circumstances, no benefit can possibly result from the
use of such a bandage.

228
APPENDIX.
The band which passes around the body is unyield-
ing, which is another source of great annoyance to the
patient, from its constant pressure.
The thigh-straps are also constructed of the same
material, unyielding in its nature, and consequently
binding upon the limbs when in a flexed position.
fitne
There is a form of suspensory which is imported to
this country from France and other parts of Europe,
called the French Suspensory. The sac of this appara-
tus is sometimes made of cotton, but more frequently
of silk. This is far inferior to the American article,
notwithstanding which, many of them are sold, and at
a very high price.
It may be justly remarked in this place, that most
of our instrument-makers frequently throw articles of
a very inferior manufacture into the market, partly on
the score of economy, and partly to cater for a vitiated
taste in favour of foreign articles; but this is a gross
error.
Proposed means for the Cure of Varicocele by Opera-
tions.—There are several modes of operating proposed
for the cure of this disease, each maintaining a certain
amount of reputation. It is not my intention here, to
give a detailed account of any of these plans, but merely
to notice each in passing.
Compression. This mode of treating the disease
was introduced by M. BRESCHET, of Paris. It has been

APPENDIX.
229
practised by him in the following manner: the veins
are seized between two pieces of metal which are held
together by a screw, the object of the operator being
to bring on inflammation and obliteration of their
cavities.
oda
Dr. WARREN, of Boston, who has repeated these
operations in the Massachusetts General Hospital,
declares, that he never could prevail on his patients
to keep the instrument on long enough to effect the
desired object. "The last," says he, "to whom it was
applied, took off the screw a short time after its appli-
cation, walked out of the hospital, and has never been
heard of since."
This is precisely what we should expect, from the
impossibility of applying the instrument without in-
cluding the nerves which pass down to the testicle.
desi asmoling of bobrofe
I have seen patients who, having submitted to this
operation, described the pain as being beyond endu-
rance, one of whom has placed himself under my care.
Compression of the vessels of the cord has been re-
sorted to, for the cure of variocele, in the Pennsylvania
Hospital, but without success. I have seen the opera-
tion attempted in one case only, but the patient threw
off the instrument.
Ligature of the Spermatic Veins.-This consists in
passing a ligature around the spermatic veins, excluding
the vas deferens. Aside from the danger of inflamma-

230
APPENDIX.
tion of the veins in this operation, should the artery be
included in this ligature, a wasting of the testicle and
consequent destruction of the organ will follow. Dr.
WARREN, of Boston, has performed this operation once;
he excluded the vas deferens, but does not give us any
account of the effect produced on the testicle, or whe-
ther the artery was included in the ligature. The same
operation has been frequently performed in the United
States, but no accurate accounts of the results have
been made public.*
Ligature of the Spermatic Artery.-Passing a ligature
around the spermatic artery for the cure of varicocele,
has been performed and reported in this country, but
I am induced to believe, with no very great success,
as the practice has not, to my knowledge, received the
sanction of the profession, nor has it attracted that
attention which the subject would have demanded had
the desired relief been afforded. The gentleman last
quoted, in his late work on tumours, says: "one patient
who had been operated on in this way, came to me
afterwards, having received no benefit."
* "Mr. Home has tied up the spermatic vein for the cure of this
disease, but the symptoms consequent were exceedingly severe, and
unless in cases of enormous distension of the veins, the operation
ought not to be performed."-Dorsey's Surgery.
"It was formerly the practice, when the veins were in a varicose
state, to tie and divide them; but it is a practice replete with dan-
ger; therefore let me exhort you never to sanction it. Another
overwhelming objection to the operation is, that when it does not
prove fatal, its ultimate effects are perfectly nugatory."-Sir Ast-
ley Cooper's Surgery, with notes by Castle.

APPENDIX.
231
Excision or Extirpation of the Spermatic Veins.-This
operation consists in laying the skin open along the
tract of the cord, and removing a portion of the vein
entire. Should hemorrhage follow, ligatures are to be
employed.
This operation is, perhaps, safer than any other that
has been proposed; but the objections to it upon plain
anatomical principles, whether the ligature be employed
or not, will be stated hereafter.
Dr. WARREN, of Boston, has performed this opera-
tion several times; but in one instance sloughing fol-
lowed, and the operation resulted in the loss of the
loss
testicle.
The simple division of the vein with the knife has
also been proposed.*
203
TEL
Removal of the Testicle.-During my pupilage I saw
castration twice resorted to, for the purpose of giving
relief in this affection. In one instance, both testicles
were removed; in the other, one only.
In the first instance, no support was ever given to
the parts prior to the operation!
* "Extirpation of the diseased veins has been practised by some
modern surgeons, in cases of cirsocele attended with severe pain
and extraordinary enlargement of the cord and testicle. I have
seldom met with cases requiring an operation of the kind."-Gib-
son's Surgery.

232
APPENDIX.
The impression made upon my mind while witnessing
these operations will never be erased, and has served
not unfrequently to bring up the subject of varicocele,
in the course of my reflections.
The removal of the testicle* was common among
the older surgeons, and patients have frequently sub-
mitted to this operation for the cure of hernia as well
as varicocele. I never saw a case of varicocele justi-
fying or requiring an operation of any kind.
As the disease under consideration is closely allied
to hernia, and not unfrequently accompanies it, and as
it is so very commonly mistaken for it, I have been
consulted, during the last five years, in a great many
cases of varicocele. Many of them have been from a
distance, and not a few, very difficult in their nature,
where the veins were greatly distended. My success
in affording relief will be given hereafter.
Upon a careful review of the various operations
which have been proposed for the cure of varicocele,
it is evident that no certainty of such a result has been
afforded; that the danger attending all these operations
is evidently more to be regarded than the difficulty
attending the disease itself. This danger does not
necessarily involve the life of the patient, yet the ill
*This is one of the most simple operations in surgery; but before
it is undertaken, be cautious that the disease does actually require
to be removed, and particularly bear in mind the circumstances
which should regulate its removal.-Sir A. Cooper's Surg., with
notes by Castle.

APPENDIX.
233
consequences resulting from inflammation of the veins
are well known to all surgeons.
Anatomically; it is evident that throwing a ligature
around the spermatic artery, thereby cutting off the
blood from the testicle, must immediately produce a loss
of its function, and more remotely endanger the destruc-
tion of the organ itself. Those who advocate this mode
of treatment may, perhaps, take caution from the fate of
Professor Delpech, of Montpellier, who was assassin-
ated by a man who had lost the testicle by an operation.
In addition to immediate results of a serious cha-
racter, the application of ligatures to the veins of the
spermatic cord produces, ultimately, the same con-
sequences with the ligature of the artery; because it
suppresses, with equal certainty, the nutrition of the
organ by arresting the circulation within it.
The means employed by myself for the relief and
cure of varicocele consist in the mechanical measures
aided by local treatment, without operation.
The instrument as now employed, and figured at
page 223, has been used by several gentlemen in this
city for some time past, and it has given universal
satisfaction. I have never met with any case, however
obstinate in its nature or painful to the patient, in which
it was used without relief. bod torna
The gentleman who is the subject of the note, p. 218,
is now wearing the suspensory, and informs me that
29

234
APPENDIX.
he is free from pain, and suffers no inconvenience from
his disease, and that the veins are diminishing in size.
The prospect of cure in cases of so long standing,
and when the veins are so enormously distended, will
be spoken of hereafter.
In the early part of March, 1837, a gentleman con-
sulted me respecting a varicocele under which he had
laboured for about two years. He is tall and erect in
person, about six feet in height, and muscular. The
tumour was of moderate size, exhibiting the appearance
of a small omental protrusion.
I applied one of the suspensories, which he wore
constantly for four months, adhering strictly to my
advice, and never removing it except when in the re-
cumbent position, for the purpose of bathing the parts,
or for changing the instrument. The vessels were
invariably found as free from blood when the instrument
was removed, as those on the opposite side, and were
observed to have contracted from time to time, under
its use.
September 20th.-I have examined this case on seve-
ral different occasions since the removal of the sus-
pensory, and also to-day. There is no appearance of
the return of the disease; the side which was the seat
of the affection cannot be distinguished. The gentle-
man informs me that he has never felt any pain in the
cord since the first few days of the use of the sus-
pensory.

APPENDIX.
235
This patient has been examined by Drs. R. COATES,
BOND, WARREN of New Orleans, and GAGE of New
York.
In the month of June of the present year, Mr.
a gentleman in good general health, and unusually ro-
bust and muscular, requested my advice respecting a
tumour in the scrotum, which he thought was a rupture.
I found him labouring under varicocele of the left
spermatic cord. The disease had been obvious but a
few days, and was supposed to have been produced by
standing at the desk. He was by profession an ac-
countant.
I applied my new suspensory, directing him to wear
it day and night. I also ordered him to remove the
suspensory after retiring, to bathe the part with cold
water every night, and to reapply the instrument after
this operation.
He has used the instrument up to this date, (Sept.
17th.) He has experienced no pain nor inconvenience
from it excepting in one instance, when some chafing
was produced, owing to his having drawn the body-
band and thigh-straps too tight. I directed them to
be loosened, and the parts dusted with carbonate of
zinc, and this difficulty soon disappeared. He is now
believed to be cured.
April 3d, 1837.-Mr.
aged 32 years, had la-
boured under a varicocele of both sides for twelve years.

236
APPENDIX.
He is accustomed to hard labour and heavy lifting, but
is not aware that his disease was produced by over-
exertion.
His scrotal tumour resembled a hernia of uncommon
size, and had none of the appearances usually described
in the works of various surgical writers as character-
izing varicocele: in short, it could hardly be supposed
that the veins could tolerate such distension.
This patient had suffered greatly from pain in the
testicle, which had extended up the cord into the abdo-
men, and had often confined him to his bed. norcje
The blood in the veins was carefully returned to the
abdomen, and the instrument was applied without pro-
ducing any unpleasant effects, although such a result
was anticipated.
I can hardly expect a cure to follow the use of the
suspensory in so difficult a case as this; yet the venous
tumour has decreased considerably under the treat-
ment.
He has bathed the scrotum and cord with iced water
daily since the first application of the suspensory.
The testicles are not in the least concerned in this dis-
ease, but are unusually large, and their gravitation
has, no doubt, aided in increasing the severity of the
affection.
He has worn one of the common suspensories for

APPENDIX.
237
several years. I removed it. It did not keep up the
testicles.
On the 2nd of May, 1837, Mr.
, aged 21
years, about five feet three inches in height, of good
general health, and accustomed to active exercise, was
assisting in loading timber; and, while bearing a great
weight, distinctly felt something give way in the cord
near the testicle. He immediately examined the part,
and for the first time discovered a tumour.
He con-
sulted a practitioner in the city, who referred him to
my care.
Upon examination, I found a small varicose tumour.
I applied a suspensory which he has worn constantly,
and ordered bathing to be employed in the manner
directed in other cases.
The varicose tumour has entirely disappeared. No
relaxation from his usual business habits has been
required.
9
During the year 1835, Mr. aged 21 years, six
feet in height and muscular, was attacked with a swell-
ing of the right testicle, which yielded to appropriate
treatment, but was followed by a swelling of the epi-
dydimis and varicocele of the cord. Not finding relief
in the city immediately, he was induced to go to Eu-
rope for medical aid. He remained in France and
England until about the first of August, 1837, when he
returned to Philadelphia with his varicocele in no bet-
ter state than it was at the moment of his departure.
uso miw allowe
—

238
APPENDIX.
The treatment recommended by European surgeons
was in accordance with that usually employed in this
country-the use of the cotton or silk bag suspensory.
30, Drs.
19: bour
On the 8th of September he consulted me in his case.
I found the veins still enlarged, the epidydimis swollen
and very tender on pressure. He was wearing one of
the French suspensories before spoken of, and now in
my possession, which did not prevent the testicles
from falling as low as when the article was removed.
In addition to this difficulty, he had become ruptured
on the left side, and was wearing a German instrument
constructed on the plan of the old trusses figured in
my work on Hernia, p. 45.
ed of
He was unable to attend to his business, the pain in
the testicle being constant, and extending up the cord
to the abdomen. It had also been supposed that the
kidney of the same side was affected, from the pain
which he always felt in the lumbar region. This pain
was increased when any jar of the body was produced
by accidents, such as stepping down a curb-stone while
walking in the city.
Sept. 9th. I applied a suspensory, which brought
the testicles in close contact with the body at the root
of the penis. I ordered the parts to be bathed with
lead water every morning and evening, while the pa-
tient was in the recumbent position.
sidols
-
Sept. 11th. He has had but
and none in the testicle to-day.
little pain in the side,
He walks with caution.

APPENDIX.
239
13th.-I drew the body-band and thigh-straps some-
what tighter than at the first application.
15th. He is now able to walk with a free step, and
with ease.
The epidydimis has diminished to nearly
its usual dimensions; the pain in his side has left him,
and he has joined his partner to-day in the active busi-
ness of a wholesale and retail house in this city. He
is also under treatment for his hernia."
It is common to meet with patients who have suffered
and are still suffering under this disease to such a de-
gree that they are incapacitated for active business.
Such patients I have never failed to relieve, and gene-
rally in a few hours after the application of the sus-
pensory. It may be considered as established, that
all cases of this nature can be relieved, and the patient
made comfortable by the use of a proper suspensory.
It may naturally be questioned how large a propor-
tion of patients will be permanently cured, and what
constitutes a cure: I may reply, that when the disease
has been produced from any cause calculated to injure
or destroy the contractile powers of the veins, or when
the veins have become greatly distended for a series
of years, freedom from pain and comfort to the patient
is all that can be expected. But when the disease is
of short duration, the valvular arrangement in the veins
entire, and the veins themselves not excessively dis-
tended with blood, then, not only relief, but a radical
cure can be confidently looked for, under the use of
proper instruments and appropriate treatment.

240
APPENDIX.
Sear
elley
Esed
corse a
IMPROVED VAGINAL SYRINGE.
From the American Journal of the Medical Sciences.
Sasoline oved one atcoito
92
E.
BY HEBER CHASE, M. D.
19
horebi
D
Ot
beat
Spa
The superiority which this instrument possesses, con-
sists in its perfect adaptation to the anatomical form
of the organs of generation.

APPENDIX.
241
A, The cylinder, is about five inches in length, with
a calibre of one inch. Projecting from its lower ex-
tremity, B, at an angle of about eighty-five degrees, is
a tube of one inch and a half in length, and six lines
in diameter—terminating at C by a male screw in the
shield D-now to be described.
The shield is of a conoidal form, produced con-
siderably near the truncated summit, and laterally com-
pressed; about four inches in length, half an inch in
diameter at the apex, and has about three inches ver-
tical and two inches transverse diameter at its base.
The superior extremity of the vertical diameter rests
against the cylinder of the instrument, while the in-
ferior extremity is carried backwards and downwards
so as to press on the perinæum a few lines poste-
riorly.
Upon the extremity of this shield is placed an ivory
tube, E, extending one third of its whole length. This
tube, from its connexion with the shield at C, is gradu-
ally increased towards its extremity, and terminates
with a diameter of ten lines, where it is perforated by
from twelve to fifteen holes all around its bulbous ex-
tremity. The ivory tube may be removed from the
shield at C, where it is attached by means of a screw.
The shield itself may be removed from the instrument
in the same manner, and at nearly the same point.
Directions for use. The bulbous extremity of the
instrument should be introduced into the vagina and
carried backwards and upwards nearly or quite to the
30

242
APPENDIX.
os uteri, the base of the shield closing the vagina at
its orifice. When the contents of the syringe are
thrown into the vagina, the fluid, of whatsoever nature,
is projected not only against and around the os uteri,
but cleanses also, by means of the numerous orifices
in the bulb, the other parts of the canal, while the
shield prevents its escape.
The advantages arising from such a combination of
parts in this instrument, will be seen at a glance by the
practitioner; and, aside from the good resulting from
keeping the organs in a cleanly state, great advantage
will be derived in disease of those parts by the use of
medicinal liquids, which can be thus applied with suffi-
cient force to reach all parts with certainty.
There is evidently a want of attention on the part
of females in the middle and lower walks of life in
keeping the urino-genital organs in a healthy clean
state; and there can be little doubt that prolapsus of
the uterus, of the first and second degree, may take
place from this inattention, as the organ is often re-
stored to its pristine state by rest, frequent ablutions,
and the daily removal of those viscid secretions which
must have more or less influence in debilitating the
parts. With these precautions, and the use of cold
and stimulating injections, the vagina resumes its tone,
and the uterus again receives proper support.
The syringe is made of the usual material, (pewter,)
with the exception of the bulbous extremity of the
shield, which, as before stated, is of ivory. In manu-

APPENDIX.
243
facturing the instrument, care should be taken that the
shield be highly finished, and the holes in the bulbous
extremity be made smooth, so that no friction upon the
internal parts may follow its use. Ivory is far prefer-
able to bone or other substances for forming the bulb,
from the facility with which it may be polished.
Cof
Asso'n






Boston, October 16, 1837.
DEAR SIR,
I take pleasure in sending you the "Ultimate Report
of the Committee of the Philadelphia Medical Society on
HERNIA." Their unqualified approval of the Instruments of
Dr. Chase, as stated in the Preliminary Report, has received
additional strength from the experience of the interval of
time that has transpired between the publication of the two
Reports. The success that has attended the practice of these
instruments in the treatment of Hernia, clearly demonstrates
that this department of Surgery has been too slightly regarded
by our profession. A great change of opinion on this subject
has however been effected in a brief period of time, by the
convincing force of facts-and it is sufficient encouragement,
that the attention of the profession is now directed to their
perusal, in these two elaborate productions.
Any information, on the subject of these instruments, will
be freely given by the undersigned; and in giving attention
to the treatment of Hernia, next to relieving suffering hu-
manity, he is ambitious to merit, what has been so generously
offered, the support and encouragement of his professional
brethren.
E. W. LEACH, M. D.
No. 134 Hanover Street.


ARTES
LIBRARY VERITAS
UNIVERSITY OF MICHIGAN
TITL
LALURE TO
TCEBOR
SCIENTIA
OF THE
1-QUERIS PENINSULAM-AMCENAM
CIRCUMSPICE
The
George E. Wantz
(UM Medicine 1946)
Collection