1413 ARTES LIBRARY VERITAS UNIVERSITY OF MICHIGAN 3100 STAULUT TRON SCIENTIA OF THE TCEBOR AIS-PENINSULAM-AMOENAM CIRCUMSPICE 358 The George E. Wantz (UM Medicine 1946) Collection Cel NOP Presentation copy dedicates. to Presented So for James Me Grigor, with the respectful Comple of The Authon. AN ESSAY ON INGUINAL HERNIA. ТИСТИКУ E С VM FO К AN ESSAY INGUINAL HERNIA; ON BY AUTHORITY OF THE PRESIDENT AND HIS COUNCIL, JOEL PITY Co 6.4 SUBMITTED, Royal College of Surgeons of Edinburgh, WHEN CANDIDATE 18y TO THE EXAMINATION OF THE FOR ADMISSION INTO THEIR CORPORATION. BY DAVID R. CUNDELL, MEMBER OF THE ROYAL MEDICAL AND MEDICO-CHIRURGICAL SOCIETIES OF EDINBURGH, AND ONE OF THE SURGEONS TO THE HULL DISPENSARY. EDINBURGH: PRINTED BY ARCHIBALD ALLARDICE. OF MEDICAL DEPARTMENT OF THE HE ARMY Nam et prius, quam incipias consulto; et, ubi consulueris mature facto opus est. SALL. CATILIN, C, I. 1823. LIB THUBMAN RD 621 .C86 YLOSE ANTH JANIUDZI AVALHORIAN OR SHE SHERIDEAL TRD нa conca 20 201SAVINAZZ 3HT OF mandait to wear, lo spelled Ingot ZHEN CVZDIDYLE HOITO SIT OTKI NORAIG dow ынт отит DYAID I COMDETT 25282T OF THE EDICVT VZD Sprco.c 301-30502 TAD ONE OF THE caseroze 10 PELETI NON SE TOD ugo poliem eirologa idutoosin alioni all enlag to 19 20 2118 EDIMBOUCH 110D BE VECHIEVED TERCERICE CH THIS ESSAY IS DEDICATED TO J. C. PARKER, ESQ. HULL, As a small Testimony of the Esteem and Regard OF THE AUTHOR. LH12 F22VA 12 DEDIGVLED TG LYBER FRO Eres uns esse 0) 3a quamites® Went » 22 JOHTUA THT TO JOHN CHEYNE, M.D. F.R.S.E. PHYSICIAN GENERAL TO HIS MAJESTY'S FORCES IN IRELAND, &c. &c. &c. THE FOLLOWING ESSAY IS INSCRIBED AS A MARK OF AFFECTION AND GRATITUDE, BY HIS MUCH OBLIGED FRIEND, HULL, 17TH MAY, 1823. THE AUTHOR. OF SI (ZAM KIYI JIH THE VOLEOT FACH OFFICED SUND SCUTITANO CHÁ HOITO-CE2 40 27AM 2 2 RINGEBED LEE LOFTOAIG DERMA 06.04.03 DHARICITE CEAEBVE TO HER VIELA OCH I 10пA CHEAME AD EURE OP ESSAY ON compling. Kor eds betrobe Dorking INGUINAL HERNIA. ni codic 903 THE treatment of Hernia, in general, being too extensive for the limits of an essay, I shall confine my remarks to the Bubonocele, or Inguinal Her- nia, which may be thus defined:- A protrusion of any of the abdominal or pelvic viscera, from their respective cavities, through the internal or external apertures of the inguinal canal. 2 To enter upon the anatomy of Inguinal Hernia, after the admirable works of Sir A. Cooper and Scarpa on that subject, I conceive to be unnecessa- ry. It is to be regretted that the former of these gentlemen, after the high encomium he so justly pays to Dr Barclay of Edinburgh, should not have adopted the accurate nomenclature of that distin- guished anatomist, which, says he, "would at once "have obviated every source of uncertainty." CAUSES. The predisposing seem to be chiefly sex, the dis- ease occurring infinitely more often in the male than in the female. Age.-Being very common in old people. Original conformation.-The disease is frequent- ly met with in several individuals of the same fa- mily. Mr John Bell says, that "often there seems to "be a hereditary disposition to Hernia in certain "houses; the form of the openings of the abdomen "being wider in a whole family, just as the features "of the face are peculiar; and I have seen a "child with all these openings so particularly wide, 3 "that, upon the slightest coughing or crying, Her- "niæ came down at every possible point;-at the navel, the scrotum, the thigh, and in the sides of "the abdomen, all at once; or, as one tumour was reduced, another arose." Climate. The disease being found more preva- lent in warm than in cold climates. 66 The exciting causes are such as produce diminu- tion of the abdominal cavity, chiefly from the sud- den or strong action of the muscles forming its pa- rietes. The most frequent are, lifting heavy weights, running, leaping, or the action of violent vomiting or coughing. Fits of crying frequently induce the disease in children. Belts or stays, which prevent the equable dilata- tion of the abdomen, must obviously tend very much to increase the effect of the causes above enumerated. Inguinal Hernia, when free from strangulation, is known by the appearance of an indolent tumour in the course of the inguinal canal, or at its exter- nal aperture, frequently descending into the scro- tum of the male and labium of the female. The tumour varies in size, being smaller or larger, $ 66 according as the patient is in the recumbent or erect posture,―larger when the patient holds his breath, diminishing, or entirely disappearing, on press- ure, and enlarging again when this pressure has "ceased;-if it be large and tense, after a meal; 66 or, when the patient is troubled with wind, soft "and small in the morning before he has taken any food; if, since the commencement of the complaint, he has been troubled with any affec- "tions arising from the unnatural situation of the "viscera, as colic, constipation, or vomiting; if he 'perceive, occasionally, a rumbling sensation in "the tumour, particularly on its return; and, last- ly, if it become tense when he coughs, so that an impulse is communicated to the hand of the "examiner."'* CC 66 66 66 66 cc The symptoms enumerated are those which are found to occur when intestine forms the contents of the tumour. When omentum descends, the tumour is found to be flabby and uneven on the surface. "If it be "free from tension, under the circumstances just "enumerated; if it return without any noise, and * Lawrence. 5 66 pass up very gradually, the case may be consi- "dered an epiplocele."* A complication of the two classes of symptoms will, in general, mark the descent of intestine and omentum together. If the Hernia remain in the inguinal canal, hav- ing only passed through the internal aperture, its existence may be very difficult of detection. The points of the fingers being placed in the direction of the inguinal canal, will, I believe, always enable the surgeon to detect the disease, when the patient is desired to cough. DIAGNOSIS. Inguinal Hernia, containing omentum, is to be distinguished from cirsocele, by placing the patient in the horizontal posture, and emptying the swell- ing by pressure upon the scrotum. The fingers are then to be put firmly upon the inguinal canal, and the patient brought into the erect posture. If the disease be Hernia, the tumour cannot re-appear so long as the pressure is continued; but, if cirsocele, the swelling will return with increased size. From hydrocele of the tunica vaginalis of the *Lawrence. 6 testis, it is distinguished by the testis being dis- tinctly felt in Hernia, in the lower and posterior part of the scrotum, by the impulse communicated to the Hernia in coughing, which is not perceived in the hydrocele. The spermatic process is distinct in hydrocele, and there is no fulness about the external aperture, and, in general, a degree of firmness and hardness in the hydrocele, which is wanting in Hernia. Encysted hydrocele of the tunica communis, or cellular substance of the chord, is not changed on the patient being placed in the horizontal posture; coughing does not affect it, and the history of the case will, in general, throw much light on the diag- nosis. The surgeons of the present day confine their practice to the reduction of the Hernia, and the ap- plication of a truss, which, when properly con- structed, and skilfully applied, affords much com- fort and security to the patient. When the Hernia does not admit of reduction, such means must be used as will support the pro- truded viscera, so as to prevent an increase in the size of the Hernia. When strangulation takes place, that is to say, when the Hernia suffers such a degree of com- 7 pression as to cause inflammation, there is a mani- fest alteration in the symptoms, and the disease be- comes one of a very alarming nature. There is considerable pain in the tumour, and a sensation as if a cord were tied tight round the up- per part of the abdomen, or sometimes only round the navel, the pain in the tumour is increased by coughing, or attempting to stand upright,-there is sickness at the stomach, frequent retching, or in- clination to vomit,-frequent hard pulse and fever, with obstinate constipation. These symptoms are to be found in intestinal Hernia ;-when only the omentum suffers strangulation, the symptoms are, in general, by no means so acute. "On examin- "ing the seat of the strangulation in Inguinal Her- "nia, it will sometimes be found at the abdominal "ring, which, from its unyielding nature, has ope- "rated like a tight cord upon the protruded omen- "tum or intestine, when more of the abdominal "viscera have passed down than the aperture would "readily admit or allow to return. This is the principal point of strangulation in old and large Herniæ; but, in other cases, it is more commonly "seated above the ring, at the place where the "spermatic cord first quits the abdomen. The strangulating pressure is here made by the trans- 6C 66 46 8 "versalis muscle and its tendon, which pass over "the Hernial sac in a semicircular direction, and by "the fascia arising from Poupart's ligament, the "semicircular border of which passes under the ddyja beit erou brey Sac."* 66 66 TREATMENT. "The indication of cure in incarcerated Hernia, "is to liberate the parts from stricture, and to re- 'place them in their natural situation."t This is to be attempted, first, by compressing the Hernia with the right hand, and, with the fingers of the left, endeavouring to push up the portion near- est to the external aperture of the inguinal canal, and in the direction of the canal, that is, from the symphisis pubis to the anterior superior spine of the ileum. To facilitate reduction, the patient should be placed in a recumbent posture, with the pelvis and thorax raised with pillows. The conse- quent relaxation of the abdominal muscles not only increases the capacity of the abdomen, but relaxes the apertures of the inguinal canal; which latter ef- * Sir Astley Cooper's Treatise on Hernia. + Lawrence on Hernia. 9 fect is much promoted by the flexion and rotation inwards of the thighs. In strangulated omental Hernia, or in intestinal, where the symptoms are not very acute, the taxis described above may immediately be had recourse to; but, where the pain of the tumour is acute, with the other symptoms in a violent degree, or where strangulation has existed for some time, bleeding, or the warm bath, ought to be first had recourse to. The taxis is often found to succeed, by perseve- rance, in gentle efforts;-violence is always to be avoided. Dovelame BLEEDING. When the taxis does not succeed, bleeding, so as to induce syncope, ought to be tried. This is best accomplished by bleeding the patient in the erect posture. WARM BATH. This remedy, which is so highly valuable in lux- ation, is found in many cases' to be equally so in strangulated Hernia; and cases are on record, in C 10 which, after the taxis and bleeding had failed, the Hernia had undergone what may be termed a spon- taneous reduction, on the patient being placed in the horizontal position in the warm bath. bed ed dr body COLD APPLICATIONS. Cold, applied locally, has been strongly recom- mended by many surgeons of experience. "This "may be accomplished by pounded ice tied up in 66 a bladder, and placed on the rupture. A solu- "tion of sal ammoniac, or of other salts, in cold "water, may be employed in the same manner."* Mr Lawrence remarks, in a note, that, if no be- nefit is derived in the course of four hours, we need not expect success from the further prosecution of the cold application. Another remedy which has a powerful effect, is the infusion of tobacco, used in the form of enema, 3i to bj of water:-one half is to be injected, and the other in a short time, if the first portion do not produce the nauseating and depressing effects which usually follow. Clysters of tobacco constitute one of the most Mao *Lawrence. bedr 11 powerful and certain means of relieving incarcerat- ed Hernia, independently of the operation; and ge- neral experience has so clearly shown their efficacy, that the knife is rarely, if ever, resorted to in the present day, without a previous trial of this remedy. cases. A variety of other remedies have been recom- mended, as purgatives, the cold bath, opiates, &c. all of which are stated to have been of use in some instances. But when strangulation has taken place, there is not time to use many remedies; I have, therefore, particularly enumerated those only which are in general use, and adapted to the generality of destr The remarks contained in Cooper's Surgical Dic- tionary, with regard to " the order in which the preceding methods and remedies should be tried," appear to be very judicious. The plan should be, while the trial of one thing is going on, another should be preparing; so, when the preceding mea- sures have been tried in vain, the application of a bladder filled with ice, or the solution of nitre and muriate of ammonia, and the injection of tobacco in the form of smoke or decoction, should never be delayed for want of due previous preparation of all the requisites. Both these measures should be practised at the 66 12 same time, immediately after the failure of the taxis, bleeding, and the warm bath. But that these trials should not occupy too much time, the following caution of the late Mr Hey may be added:- "I can scarcely press, in too strong terms, the "necessity of an early recourse to the operation, as the most effectual method of preserving life in "this dangerous disease." This has been amply confirmed by the experience of many able surgeons. The foregoing remarks apply more particularly to intestinal than to omental Hernia; for, in the lat- ter, and in large intestinal Hernia, purgatives are often very beneficial, and we may wait a longer time without increasing the danger. After persevering in the use of the above reme- dies for a certain time without success, they must be abandoned, and recourse immediately had to the operation. The time to be employed in at- tempts at reduction will, of course, vary in different cases; but it is now universally allowed, that the sooner the operation is performed, the greater is the chance of saving the patient. If the surgeon should be called in the beginning, he should ope- rate before the inflammation of the parts comes on. When he is called at a later period, it is advised, 13 that, after giving a short trial of the most powerful means, that is, to cold applications and the tobacco clyster, he should proceed to operate forthwith. Sir A. Cooper states, that, even when gangrene of the in- testine has commenced, the operation may be suc- cessful. This will encourage us to operate in appa- rently hopeless cases; as, without the operation, the patient must die. It must not, however, be under- stood to warrant any delay, when the operation can be had recourse to at an early period; for that eminent surgeon is one of those who most stre- nuously enforce the necessity of operating early. The object of the operation is to free the stran- gulated parts from pressure. Previous to com- mencing, the patient is to be placed in the hori- zontal position, with his pelvis at least as high as the rest of his trunk. It will therefore be conve- nient for him to lie on a bed, with his lower extre- mities hanging over the side. The thigh should be maintained in the best position, by placing the foot of the affected side on a chair. The hair must be completely removed from the tumour and sur- rounding parts, and the bladder should be emptied. The operator, being seated between the thighs of the patient, makes his first incision, which should begin an inch above the external angle of the aperture, 14 extending over the summit of the tumour to its lower part. After the integuments are divided, we perceive the fascia lata, consisting of cellu- lar membrane, with a few tendinous fibres. This must be carefully divided, at one point; a de- pending one is generally preferable. We proceed in the same way with the sheath of the cremas- ter muscle, which is below the fascia. There is then (at least in recent Hernia,) a portion of loose cellular substance; and immediately below this is the peritoneum, or true sac of the Her- nia. All these parts are to be divided. The cau- tions given by the late Professor Scarpa appear to be so excellent, that I shall transcribe freely from the able translation of Scarpa's work, by Mr Wish- art, to whom the greater part of English surgeons are much indebted for their acquaintance with the works of that accomplished surgeon. "In scrotal Hernia of moderate size, the cellular "substance which accompanies the peritoneum out " of the abdomen, and which is interposed between "the sheath of the cremaster muscle and the her- "nial sac, is merely a soft smooth cellular substance. "In large and old scrotal Hernia, on the contrary, "this same cellular substance is dense and compact, " and apparently composed of many layers. The 15 "aponeurotic sheath of the cremaster also acquires, "in old Hernia, a hardness and thickness much greater than usual; on which account, in both 68 cases, pathological anatomy teaches us, that we ought to proceed very cautiously in making the opening into the hernial sac, in order to lay bare "the viscera contained in it without wounding "them; for, in scrotal Hernia of moderate size, and "not of long standing, after dividing the sheath of "the cremaster with the hand unsupported, there "will present immediately under it the soft cellular "substance which accompanies the peritoneum through the inguinal ring; and after raising and dividing it, the true sac formed by the peritoneum "will shine through. And, in the second case, of large and old scrotal Hernia, as it will be impos- "sible to determine in every individual the degree "of thickness and depth of the cellular substance interposed between the sheath of the cremaster " and the hernial sac, it will always be prudent for "the surgeon to proceed cautiously in similar cir- "cumstances, raising, with the forceps and pointed "director, and dividing, layer after layer, the firm "cellular substance lying under the sheath of the “cremaster, until there appears in the bottom of the incision the transparent membrane which 66 56 66 66 66 66 66 16 "constitutes the true hernial sac formed by the "peritoneum. Whoever shall deviate from this "rule will run the risk, in the first case, of plunging "the knife in upon the viscera; and, in the second, "of taking for the hernial sac the firm and thick "cellular substance with which it is covered." The parts above enumerated being all divided with great care, at a depending part of the tumour, and a director being introduced, we are enabled to lay all the coverings open at once, instead of mak- ing so many separate dissections. It has been before stated, that the seat of strangulation may be either at the external or internal aperture of the inguinal canal. When the former, a director is to be introduced a little way into the neck of the sac, within the aperture of the tendon, and, with a probe- pointed bistoury, the stricture is to be cut directly upwards, parallel to the linea alba, beginning at the middle of the superior border of the aperture of the inguinal canal; and no further division is to be made than what is necessary to free the parts from stricture. When the strangulation is found to be in the latter situation, that is, at the internal aperture of the inguinal canal, an inch and a half to two inches from the external aperture, in a direction towards 17 the anterior superior spine of the ileum, it is there occasioned by the pressure of the tendon of the transversalis, which passes over it, and by the re- sistance of the border of the fascia which passes under it."* If the stricture be at this orifice, it is to be divided in the following manner: The finger is to be passed up the sac, and through the external aperture, until it meet the stricture; the probe- pointed bistoury is then to be introduced within the sac, with its flat side towards the finger, the finger being still a director for the knife. The knife being carefully introduced under the stricture, and the edge turned forward by a gentle motion of its handle, the stricture is to be divided directly upwards, parallel to the linea alba, and so as to allow the finger to slip into the abdomen. The knife is then to be withdrawn as it was intro- duced. A thickening of the neck of the sac is said, by authors of the greatest celebrity, to be occasionally the cause of strangulation. Sir A. Cooper says,- “I have already said, it is not so frequent an oc- currence as has been imagined; it is undoubt- edly true that it does sometimes occur." Scarpa 66 66 * Sir A. Cooper. D 18 says, "That it now appears that this immediate* "cause of strangulation of Hernia ought, with great propriety, to be considered no longer as a rare accident, but rather as one of the very frequent "cases of this complication of the disease." In this case, the neck of the sac is to be divided, as already described.b Sithon 66 66 "When the stricture has been completely re- moved, the protruded intestine is to be carefully "examined, to observe whether the brown colour, "which it assumes under strangulation, lessens or disappears, as this is a proof of the return of cir- "culation in the part."+ Gybe "If the intestine appears to have a free circula- "tion, the surgeon should directly, but gradually, "return it, thrusting up about an inch at a time, "and securing each part with his fingers, until the "whole is returned into the abdomen."+ 66 66 When adhesions exist between the sac and the intestine, they should be divided with the utmost care; and where they cannot be separated, the parts of the sac which are adherent to the intestine should be cut off from the rest of the sac, and re- turned with the intestine. When a portion of omentum has come down with *The neck of the sac. + Sir A. Cooper. 19 the intestine, if healthy, and not very large, it ought to be returned after the intestine; if, how- ever, it be diseased, and indurated or enlarged, it ought to be cut off; and, should there be hemorr- hage, the vessels must be secured by small liga- tures, to be left out of the wound. If, on opening the sac, a portion of the intestine should be found to be gangrenous, the only thing to be done by the surgeon is to assist nature in giv- ing a free vent to all matters which may pass by the wound. If the patient should survive, an arti- ficial anus is formed, which may continue for life, or may gradually close, according to circumstances. TREATMENT AFTER THE OPERATION. 66 "When the operator has returned the protruded " contents of the hernial sac, he should clear it of any blood which it may contain, and bring the edges of the wound together, confining them by "two sutures. The needle and ligature should on- "ly be passed through the integuments, and great "care should be taken to avoid penetrating the (6 66 sac, which might occasion a dangerous extension "of the inflammation. A piece of lint should then 66 be laid upon the wound, with a compress of linen 20 over it, and these pressed pretty firmly down up- "on the groin by the T bandage, so as to close the "orifice of the hernial sac."* If several hours 66 elapse without an evacuation, a purgative clyster. "should be given, composed of magnesia vitriola- ta, infusum sennæ, and a large quantity of li- quid, as warm as the patient can bear it; if this "does not succeed, they may be followed by the "oleum ricini; but no purgatives should be used "until it appears probable that stools cannot be pro- “cured without them. Spirituous fomentations to "the abdomen will assist the natural action of the "bowels."* 66 66 If vomiting or cough should continue after the operation of purgatives, or after the patient should have natural stools, they are to be allayed by opi- ates. "The patient must be particularly enjoined, on "no account, to move from the horizontal position during cure, particularly whilst having stools, "otherwise the intestines will be very liable again "to descend." The wound should be dressed on the third day, and every day afterwards. If much inflammation comes on, or the Hernia is large, the scrotum must 66 450 * Sir A. Cooper. noby odt took Bist d nogu 21 be supported by a small cushion, and fomentations and poultices applied. 120 "The ligatures should be drawn away on the "fifth day, unless a high degree of inflammation "renders it necessary to remove them earlier." "After this, the cure proceeds as in a common "wound; only, the patient should be kept in bed "till it is complete."* bas nero After the wound is perfectly healed, the patient ought to be accurately fitted with a truss, which he should constantly wear. In very large Herniæ, or if they be of long stand- ing, it is better (should strangulation take place,) to divide the stricture without opening the sac, or attempting to reduce the protruded parts. On the other hand, should the Hernia be very small, so as not to protrude at the external aper- ture of the inguinal canal, but to remain in the canal, and become strangulated by the border of the transversalis muscle, the operation is to be per- formed in the following manner :-The incision is to be begun over the tumour, half way between the symphisis of the pubis and the spinous process of the ileum, and extended downwards parallel to Paupart's ligament, as low as the abdominal ring. * Sir A. Cooper. ilg 22 This incision, which only divides the integuments, exposes the tendon of the external oblique muscle, which, being next cut through in the same direc- tion, without cutting the abdominal ring, the her- nial sac comes into view, extending from the abdo- minal ring to the opening at which the spermatic cord quits the abdomen. The sac is then to be opened, and the border of the transversalis to be di- vided by a probe-pointed bistoury ;-the operation is then to be finished as has been already de- scribed. It now only remains for me to say a few words on the varieties of Inguinal Hernia, of which I have not yet spoken. The one congenital, in which the Hernia is contained in the tunica vaginalis of the testis. Should this Hernia become strangulated, the ordinary operation is to be performed, the surgeon remembering that the tunica vaginalis is the cover- ing of the Hernia, instead of the usual peritoneal coat.* The other variety to which I have alluded, is that in which the Hernia, instead of making its way through the inguinal canal, following the course of the spermatic cord, forces itself through the fibres * Mr Hey mentions a case, in which the proper hernial sac was found within the vaginalis. 23 of the internal oblique and transversalis muscles, directly opposite the external aperture of the ingui- nal canal. In this case, the epigastric artery, instead of be- ing on the inside, is on the outside of the neck of the sac; that is, further from the linea alba; and the incision of the stricture is to be directed ob- liquely inwards and upwards. I have endeavoured, as concisely as I could, to treat of Inguinal Hernia. I am conscious, how- ever, that the limits assigned to a probationary essay are quite inadequate to do justice to a sub- ject of so much importance, even were it ably handled. I therefore beg, that the Fellows of the Royal College who may do me the favour to peruse this essay, will view its imperfections with kindness. Printed by A, Allardice. THE END. geloemer zilantad pie surgild uport di ingat out to entise od appellaćago (roarh 091908 190S Jauss In od 15 Booteat. nutie ontésehra 93 Car To 2500 eat to abiatuo od no si chiari oft no qui busedia somit or moit druh tu But one or do belobub od of a oroitia edi olani ads u bns th of bluco I en visalones an horsebagavad wod epohero Tsinoff Wntoru visnoitadors of bogglers eftall od sadh 975 -dua s of sonant ob of eleghatan vids Ji otow more common doum e lo spot Lyo ods to avolio Left I die eetron of seochaid die zuchfoozed 910lored 1 a odw orolo 11 17 DISSERTATIO MEDICA INAUGURALIS DE HAEMORRHAGIA UTERI PUERPERA; QUAM, ANNUENTE SUMMO NUMINE, EX AUCTORITATE REVERENDI ADMODUM VIRI, D. GEORGII BAIRD, SS. T. P. ACADEMIAE EDINBURGENAE PRAEFECTI; NECNON AMPLISSIMI SENATUS ACADEMICI CONSENSU, ET NOBILISSIMAE FACULTATIS MEDICAE DECRETO; Pro Gradu Doctoris, SUMMISQUE IN MEDICINA HONORIBUS AC PRIVILEGIIS, RITE ET LEGITIME CONSEQUENDIS; ERUDITORUM EXAMINI SUBJICIT DAVID ROSS CUNDELL, Scotus, COLLEG. REG. CHIRURG. EDIN. SOCIUS. "In all cases of danger, these in particular, the safety of the parent, and the preserva- tion of the child, are events which give inexpressible satisfaction, and adorn the reputa; tion of the practitioner." Denman's Introduction. Prid. Kalendas Augustas, horâ locoque solitis. EDINBURGI: EXCUDEBANT J. PILLANS ET FILIUS. M.DCCC.XXVI. ADIGAN OFTA TUZIO DODAL OM HOOTED BOOTH VOR ASUS MINTU AIDAN SOMAN STARCHON 109 NAUT incia arxa BAUAXIC ORDE D GEORGII BYLED 27 b 150 RULES JORNADA ETAkas HaNMA 2004 93 DVAID FOR GONDERF EDIADOUCE aitilos opposel rodentA boola bi DOGC 220 PORE 012409e JACOBO M'GRIGOR, M. D. TLA EQUITI AURATO, CONCILII MEDICI MILITARIS QUI IN OMNIBUS ORBIS TERRARUM REGIONIBUS COMMILITONIBUS SUIS AEGROTANTIBUS OPEM TULIT; QUI RECTORI GENERALI; IN BELLO GALLICO TAM FELICITER CONFECTO, CONCILIIS MEDICIS PRAEFUIT VIGILANTIA NON DELASSANDA; QUI DOMI MILITIAEQUE SCIENTIAS MEDICINAM ORNANTES STUDIOSÈ FOVIT; EAS DIU FAUTURUM PIE VULT AUCTOR. 17COBO CHICOEND CTATUA ITIUOS CONCIPI MEDICI NITALYFIR BEGT GERESYL 100 12 OKTATEOS OREI GENEVEDA FECLOZIRGS arue augmTORY OTTORIPE FAUT HO SEITO GIFTICO 1 ARTICKLER COR/RGIC COMOITTE MEDIGA BBVAADES Sid/ISTAGRAM O LITZAIONY JU ORAITSINE THEDA 13000 OUTY CELIO TEAMS MUHUTOA URL BAIL SOTOUA MERAH 600 one 113900 gee 309900 filemen arbisch eas DISSERTATIO MEDICA obchen obero not INAUGURALIS mubnog le HAEMORRHAGIA UTERI PUERPERA. DE or POST Mau auf I 90 how doseg In hac dissertatione inaugurali, de Haemorrha- gia Uteri solummodo tractare intendo, quae vel breviter ante vel post partum, aut inter parien- dum invadere solet: omissis omnibus quae foetu adhuc immaturo oriuntur, aut quae cum pecu- liaribus catameniae conditionibus connectuntur, aut quae demum morborum uteri symptomaticae sunt. Haemorrhagia Uteri ita restricta, propriè ut existumo, puerpera nominari potest, et verbis se- quentibus est definienda. Sanguinis fluxus abnormis ex uteri vasis, cum B 20 DE HAEMORRHAGIA UTERI PUERPERA. placenta, vel membrana decidua communican- tibus, ad tempus laboris accidens.* In divisiones sequentes separare convenit. a, Occurrens,, ante partum periodo gestationis prope confectâ. inter pariendum. post partum, placentâ nondum 1Яexclusâ. 10AFSTOMSAH d, post exclusionem placentae. Prius quam pathologiam Haemorrhagiae Puer- perae investigare incipiam, utile fore, credo, nexum vasculosum, qui inter matrem et foetum existit, paucis verbis exponere. b, C, Placenta e congerie vasorum sanguinem ve- hentium praecipuè constat, in tela cellulosa, spon- giosa, subrotunda, quae plerumque ad fundum uteri, rarò ad partes alias adhaeret. Erga finem graviditatis, arteriae uterinae mul- tùm adauctae, sanguinem maternum ex uteri substantia, in cellulas placentae spongiosas, li- berrimè immittunt, et sanguis in venas aut sinus uterinos redditur. ni hele sigtennenergia * Haemorrhagia funicularis adeò rara est, ut definitionis accura- tionem non afficiat ; et strictiùs loqui non uterina est, nam sanguis effusus est foetalis. DE HAEMORRHAGIA UTERI PUERPERA. 3 Sanguis foetalis quoque per arterias umbilicales in placentam fertur, et per ramos innumeros sub- stantiam ejus permeat. Arteriae umbilicales contactum habent minu- tissimum cum sanguine materno, sed intercom- municatio vel anastomosis nulla est. oda b Hic perita benevolentia Magni rerum Opificis, in clara luce videtur; nam ne omnino pereat em- bryon, per cursum rudem et instabilem sanguinis materni, communicatio omnis negatur. Praeter nexum jam memoratum, uteri super- ficies cum membrana decidua connexionem ha- bet vasculosam, intimam. Haemorrhagia uteri incerto tempore oritur, et multùm variat secundum quantitatem et rapidi- tatem fluxus. Interdum dolor nullus est, aut admodum lenis ; interdum contractio musculorum uteri, admodum fortis, et dolor lumborum partiumque vicinarum, comes sequitur necessarius. Nunc accessus inopinatus est, et sine signo aliquo monitorio; nunc menses adesse putat foemina. Verbis felicibus utar si liceat, viri in arte ob- stetrica exercitatissimi, 4. DE HAEMORRHAGIA UTERI PUERPERA. "The hemorrhage may come on in every dif- "ferent situation; in bed she may awake sud- "denly from a dream, and find herself swimming " in blood; or it may attack her when walking; " or may be preceded by a desire to make water, "and she is surprised to find the chamber-pot "filled with blood."* wood athou In multis exemplis jactura sanguinis immensa est, et aegra in summo periculo brevì deducitur, immo in horae sextante, de ea conclamatum fuit! In his exemplis, placentae separatio, plus mi- nusve extensa, plerumque accidisse invenietur. rous sed Bat CAUSAE Primae speciei sunt, Status corporis debilis, ac- tionem uteri sanam afficiens-Excitatio vehemens omnis ab animi affectu, ve causa quavis alia cir- cuitum sanguinis incitante-Pressura vestimen- torum-Concussio a violentia externa-Conatus omnis, vel exercitatio praeter vires-Medicamina seu potius venena amblotica-Morbi quidam, ve- * Burns' Midwifery. DE HAEMORRHAGIA UTERI PUERPERA. 5 luti Variola-Tussis violenta.* Causae jam me- moratae, morbum de quo agitur saepe inducunt: adhaesio vero placentae ad os vel cervicem uteri causa est Haemorrhagiae silentio haud praeter- eunda, haec enim inevitabilis est, et valde peri- culosa.roat necmt-dogane telle aigars th Secundae speciei causae. Adhaesio placentae ad os vel cervicem uteri-Circuitus sanguinis fortis a stimulis adhibitis-Festinatio obstetrici ignara-Puerperium diutinum exhauriens-Funis ruptura.t Tertiae speciei causae. Funis Vellicatio Placentae retentio, vel ab adhaesione morbida, inaequali; vel ab uteri contractione spasmodica, clepsydrica Coagula in utero formata, contrac- tioni ejus obstantia-Atonia vel status uteri lan- guidus, in quo sese contrahere nequit. Quartae speciei causae. Foemina in toro re- sidens, paullo post prolem editam-Mutatio stra- gulorum intempestiva-Atonia, ut in specie ter- tia. BULOU * Multae causae hic enumeratae, ad species alteras referunt. + Baudelocque se vidisse memorat, ex hoc fonte, quantum duos pileos impleret! all grobiso 6 DE HAEMORRHAGIA UTERI PUERPERA. HET MALA DERE KO 397 -istokis Vaido! eatstour eives for to be outm olesa saltbg Haemorrhagia primò occurrens, et si sit levis, nulla fere praebet signa, quibus comperi potest, ni e vagina effluat sanguis-Impetu haemorrha- giae tamen saepe redeunte, et sanguine in ma- jore copia prorumpente, symptomata infausta comitantur, pro rapiditate et magnitudine fluxus -Extrema scilicet frigida-Vultus pallidus ex- sanguis-Aspectus anxius delirans-Deliquium animi repentinum-Debilitas pulsus, qui inter- dum percipi nequit-Oculorum anxietas (wild- ness)-Ventriculi irritatio ut contenta retinere nequeat Tremor convulsivus-Jactitatio-Sitis urgens-et ni remedia aptissima, opportunè, et assiduè adhibeantur, vita cum gemitu fugiet. Per usum remediorum tempestivum, parti mag- nae symptomatum verè acerbissimorum saepe praeveniri potest; et ad SYMPTOMATA. REMEDIA, Quae in prima specie usurpanda sunt nunc pro- cedere fas est. ton nola8950 DE HAEMORRHAGIA UTERI PUERPERA. 7 Simul atque incipit haemorrhagia, gravidam in positione horizontali, in lecto ponere oportet, capite ejus paullo depresso, pulvinis semotis- Linteola in aqua frigida, aut in aceto et aqua immersa, assiduè ad vulvam foeminae et dorsum sunt applicanda, ad extrema quoque si necesse erit. Aër frigidus circa lectum, liberè admitten- dus. Quod ad applicationem frigoris attinet, cautela necessaria est. In primo haemorrhagiae impetu, viribus paullo imminutis, liberè appli- cetur frigus, ut jam diximus, et summo cum fructu. Post plures tamen haemorrhagiae re- gressus, debilitas magna est, et extrema saepe frigida sunt, cum pulsu debili et signis aliis im- minutae vis nerveae. In hoc casu, applicatio frigoris strenua multum noceret, propter effectus ejus sedativos.-In extremis casibus, ubi vires vitales multùm reducuntur, vice frigidorum, panni calidi ad stomachum et extrema sunt ap- plicandi: "and it is in these cases that benefit has "sometimes been found, by a still wider depar- "ture from the ordinary rules of practice, and the "allowance of a little cold negus. So that the "utmost degree of judgment is necessary on this "occasion, not only how far to carry the estab- 8 UTERI PUERPERA. UTERI DE Е НАЕ 66 lished plan, but on peculiar emergencies how "far to deviate from, and even oppose it."* HAEMORRHAGIA Constipationi obviam eundum est, salibus neutris frequenter adhibitis, in dosibus minutis. Examinatio per vaginam nunc instituenda est, ut quam correctissimè dignoscantur uteri status et fluxus causa. In pulsu scrutando, si activitas vasorum mor- bosa invenitur, venae sectio multùm prodest, et interdum cum remediis jam enumeratis, fluxum sanguinis omnino tollit, causa ejus sublata; caveat autem obstetricus, hoc remedio ne utatur, ni indicatio in aprico sit: pulsus scilicet plenus, fortis, et forsitan praegressis aut instantibus febriculae signis. Foeminam in lecto firmo affixam, per paucos dies remanere oportet, grave ne rediret malum. Examinatione habita, si obstetricus placentam se non offerre putet,† et si os uteri parum dilata- tum et rigidum inveniat, sine ullo signo laboris, formationi coagulorum confidat, cum quiete absoluta, et remediis jam enumeratis. * Study of Medicine. M. Good. † De hac re, se non semper certiorem facere potest obstetricus, propter coagula. DE HAEMORRHAGIA UTERI PUERPERA. 09 Remedia circuitum sanguinis tardantia a qui- busdam scriptoribus laudantur, Tinctura Digi- talis Purpureae scilicet et Plumbi Acetas. Effectus eorum in hoc morbo expertum esse nunquam meum fuit. neoro signTiomond aim Haemorrhagia perstante, cuneolo* uti necesse erit, quod nihil aliud est, quam pessarium stu- peum, vel linteolum molle portionibus separatis, in vagina introductum et ad os uteri applicatum. In haemorrhagia compescenda, remedium est maxima fiducia dignum, et semel introductum, aegram summa cum vigilantia observare oporte- bit. 20 be retuslarog Brisbon enzi Jottogo Cuneolo objicitur, haemorrhagiam non extrin- secus manifestam esse; intra uterum accumulare sanguinem, cavitatem ejus multo distendentem; et symptomata infaustissima sese ostendere! Si intus effluat sanguis, et uterum distendat; aut si occurrant symptomata gravia; os uteri dilatabile evasisse, plerumque inveniet obstetri- cus.sint int tobog do Jehere slidetelib net zo sen Si finem gestationis non attigerit gravida, ut uterum gerat assiduè conari oportebit. idu ssigentiomsat na oltaridub pandeidmem ahqur brad sitnoteize Vernaculè "Plug." DECO T C 10 DE HAEMORRHAGIA UTERI PUERPERA. Magna copia sanguinis amissa, saepe multùm patitur aegra ab irritatione, ad quam summoven- dam, adhibenda est dosis Tincturae vel Pulveris Opii, pro effectibus ejus repetenda. DIN109 Sin minus haemorrhagia copiosa sit, signis magnae debilitatis praesentibus, opitulanda est foemina, per foetus inversionem, more in libris obstetricis commendato.om mulostnil lav minsq Difficultas hic subinde oritur, nam sanguis ex utero in pleno rivo effluere potest, ore ejus parum dilatato.orini tomos do murgil stor smizsm In hoc casu nihil rudis violentiae adhiberi oportet. Nisus moderati perstantes ad os uteri dilatandum sunt utendi, donec manus in uterum introduci potest, ut invertatur foetus, pedibus ejus prehensis. offum ante motives Mishingana Methodum a Puzos inventam, et a multis scriptoribus laudatam, diruptionem scilicet mem- branarum foetus, parum prodesse puto; nam cuneolus plerumque haemorrhagiae resistit, do- nec os uteri dilatabile evadat, et pedes infantis petantur. digitis non ainoitagý monit ið o Dubitatio an uteri contractio inducta erit ruptis membranis; dubitatio an haemorrhagiae resistetur, contractione inducta; resistentia haud DE HAEMORRHAGIA UTERI PUERPERA. 11 VALITSIC 1080 parum adaucta ad uterum evacuandum, si ne- cesse erit, huic methodo objiciendae sunt.ima or Exempla huic operationi fidenda sunt, quibus conatus ad uterum evacuandum sese ostendit, et haemorrhagia minuitur. Hic, methodus utilissi- des sbasveldue ma est. Si ad os vel cervicem uteri adhaereat placenta, rarò evenit ut foemina ad finem gestationis per- veniat, et multum periculi est, ne vitam amittant et mater et proles. Necesse est ad uterum evacuandum, ut supra diximus, nam vasa dirupta magni sunt diametri, et sese contrahere non pos- sunt, donec uterus vacuus evadat.ieve otis Primo haemorrhagiae impetui per usum cune- oli, plerumque resisti potest.look?I, sing In manu introducenda, ut membranae rumpan- tur, et pedes infantis prehendantur, placentam leniter ab utero separare melius est, quam sub- stantiam ejus dilacerare. Priusquam opem ferre incipiat obstetricus, Opii dosis adhibenda est, ad M. XL. vel M. LXV. Tincturae Opii, vel gr. 111. ad gr. v. Pulveris Opii.nigar Narrantur exempla, in quibus placentâ primò expulsâ, magna cum haemorrhagia, secutus est infans vivens, matre revalescente. Haec exem- 12 DE HAEMORRHAGIA UTERI PUERPERA. pla rarissima vires reverà conservativas naturae, miro modo demonstrant.obodjom bind Jins Species Secunda. Haemorrhagia in primo stadio laboris occurrens, a placentae adhaesione ad os vel cervicem uteri, modo jam praescripto sublevanda est. Non digitum solum, sed totam manum in vaginam introducere saepe necesse est, adhaesi- onem placentae insolitam dignoscere, per tacti- onem mollem fungosam, digito communicatam. Si adhibita sunt stimulantia, aut si facti sunt conatus rudes ad uterum dilatandum, placentae separatio evenire potest.oy pob ame Aëris frigidi libera admissio-Stragula te- nuia-Frigoris applicatio topica-Enemata sti- mulantia-Membranarum ruptura-remedia sunt prius usurpanda. bodang ahasini ceber qui Conatibus nostris non valentibus, aut aliter loqui, haemorrhagia persistente, duae nobis agendi methodi linquuntur: stolzdo raidoni 1mo, Caput infantis repellere, pedes prehen- dere, eosque in vaginam trahere.) revity m Baudelocque hoc sine injuria effici posse ait, etiam quum caput progressum fecit magnum in cavitate pelvis.chnoor stever guard the thera DE HAEMORRHAGIA UTERI PUERPERA. 13 2do, Vectim vel forcipem introducere,et foeminam ex aerumnis tradere.suboshi metr Nunc una, nunc altera methodus, praestan- tior invenietur, pro capitis descensu.ed Haemorrhagia in puerperio diutino occurrens, methodum jam dictam sibi postulat.op Haemorrhagia funicularis tam rarò occurrit, ut vix et ne vix quidem eam observare necesse est. In omni casu, foetum periisse inveniemus. no Species Tertia. In hac et in specie sequente fluxus rapiditas saepe horrenda est. adhiqa Causa longè frequentissima est placentae sepa- ratio inequalis, quae oriri potest, vel ab atoniae statu in fibris uteri muscularibus, quae ad placen- tam expellendam parum sufficiunt ; vel ab adhae- sione forti, vel ossificatione partis placentae. Atonia saepe sine causa manifesta occurrit. Ab- dominis circumligatio per fasciam latam, saepe atoniam impedit, et nunquam negligi debet. Haemorrhagia incipit vel immediatè post par- tum, horae intervallo, vel periodo longiùs remo- ta. Jactura sanguinis saepe adeo est repentina, ut breve spatium est in quo uti remediis. 1000 sl Capite depresso, subita frigoris applicatio est facienda, ad uteri regionem. Compressio fortis 14 DE HAEMORRHAGIA UTERI PUERPERA 73391304 ARTI AIDABETOMGHE circa uterum per manus adjutricis, et in uteri ca- vitatem introducenda est manus, non ut extraha- tur placenta, sed ut uterus per manum irritatus sese contrahat, et placentam una cum manu ex- pellat. Multo sanguine amisso, interdum tanta est uteri atonia, et vires vitales adeo sunt ex- haustae, ut manu introductâ, sese non contrahat uterus. 999 eirvisado se mobiup xiv on je ziv Necesse est stimulantia fortissima, sine respec- tu quantitatis, promptè adhibere. insTasinog? Spiritus vini scilicet, et substantiae aliae quae alkohol continent. Tinctura Opii in plenis do- sibus, pro effectibus ejus repetenda.suponi oftes In omni haemorrhagia, manum introducere non necesse erit. Compressio et frigoris appli- catio saepe sufficient. fizzo lov enote Manus semel introducta, retineri debet, donec per uteri contractionem expellatur, et compres sio externa eodem tempore est adhibenda. Si tenaciter adhaereat placenta, et in modo jam dicto separari non potest, ne fortius extra- hatur placenta per funem, cavendum est. Nam glug ita uterus invertitur. oup HU B Placenta per digitos summa cum cura est se- paranda, et quantum fieri potest integra.broo SOMOS ATU AIDAIROPEA 20 DE HAEMORRHAGIA UTERI PUERPERA. 315 ain Species Quarta. Quantitas sanguinis modica, necessario ex utero fluit, in omni partu, utcun- que sit secundum naturam. non motoroz obor Haec plerumque cum coagulis, placentam se- quitur, et cito desinit, et pro haemorrhagia non est habenda, ni abnormis evadat. soloq aile -ix Post placentam exclusam, uterus saepe bene contrahit, sed conditio haec beata non semper ma- net, nam ob causas jam memoratas, atonia uteri occurrat; teterrima lethi causa.aivel sigedron en Species Tertia in Quartam saepe terminat, et in iis curandis nexus intimus existit. Ita ut quae de tertia specie dicuntur, de hac quoque dici possint.notofftua msbasugaitze matiy be minim MAHic, manus introductio, plerumque magis est necessaria, atonia etenim magis est perfecta, et digitos intra uterum movere saepe necesse est, adi contractionem uteri aciendam. Compressio exteriùs applicata stimulantia maximè diffusibi- lia, et Tincturae Opii doses copiosae saepe repeti- tae praestantissimum habent effectum, in matrem pulchram restaurando, ut sacris fungatur mune- ribus a Deo Optimo statutis. Pulsu pleniore et firmiore evadente, stimulantia sunt parcius utenda, vel potius intermittenda. SPORA DE HAEMORRHAGIA UTERI PUERPERA. 16 Sed Tinctura Opii ad M. xx. vel xxv. horis sextis est repetenda, ad vires sustentandas, dum- modò soporem non inducat.ubuose tie sup Hoe Quantitates exiguae cibi nutrientis concoctu facilis, sunt frequenter exhibendae. Status qui- etis perfectae, maximè est necessarius, et fascia antea commendata. Secretiones alvinae maxi- mam attentionem sibi postulant. boe tidstroo Exitus lethalis interdum occurrit, quum hae- morrhagia levis momenti apparuit. Hic sangui- nem in utero collectum plerumque inveniemus. Sed occurrunt exempla in quibus utero post mor- tem examinato, sanguinis quantitas inventa est, minimè ad vitam extinguendam sufficiens.niezo Quapropter, opinionem Doctoris RAMSBOTHAM non sine ratione formatam puto," I am not "without my suspicions, that this relaxed state "of uterus itself, has a powerfully injurious “influence upon the nervous and arterial sys- "tems."*gonzoines-2020bilgo cantonit te sil De remedio, nuper in Materiam Medicam in- troducto, mentionem facere necesse forsan exis- itutede omito 69C & audr givenlimite •* Ramshotham's Midwifery. italy gelu abastiansti zbog lovsbrotu slots me DE HAEMORRHAGIA UTERI PUERPERA. 17 timetur, clavo maligno scilicet, qui in secali in- venitur. Pro emmenagogo primò utebatur. In labore diutino, ubi actio uteri languida est, clavus secalinus bono cum effectu praescriptus est, quod ad matrem attinet: sed foetus mortuus expulsus est. In haemorrhagiae casibus, ubi non profuerunt remedia jam dicta, clavi secalini decoctum prae- scribi potest, aut gr. x. Pulveris magno cum com- modo ut quidam affirmant. tex De transfusione sanguinis in venas foeminae, non est silendum. Experimenta docent hanc operationem tutò perfici posse, et non desunt ex- empla recentia in quibus, citò revalescebat mori- tura, quantitate sanguinis perexigua in venas in- troducta. Hoc remedio nunquam usus sum; et inter res curiosas ad Physiologiam pertinentes, quam inter accessiones utiles chirurgiae hodier- nae collocare mallem. divatodaze zenoloh mulemezü emolident seg fan emp US Edo DIAGNOSIS. Faniboot Nullus fere morbus cum haemorrhagia puer- pera confundi potest, exceptis casibus in quibus sanguis intus colligitur. D 18 DE HAEMORRHAGIA UTERI PUERPERA. Casus iste pro syncope duci potest. In haemorrhagia, abdominis compressio ex- pulsionem coagulorum et sanguinis efficiet, et uterus parum contractus invenietur. e PROGNOSIS. 290 Haemorrhagia nunquam periculo vacua est, et exempla haud infrequentia non desunt, in quibus, viri, meritò, prima dignitate in arte sua potiti, fortunam malam habuerunt. Periculum plerumque caeteris paribus, rapidi- tatem et quantitatem fluxus aequat. Post om- nem tamen haemorrhagiae regressum, periculum augetur. bove Haemorrhagia valde periculosa, ea est, quae sine dolore et pigrè fluit. Exemplum calamitosum mihi notum est in quo, dum per hebdomadam dolores expectavit obstetricus, ut examinationem faceret, mortua est foemina! 99.9990 mon In plerisque casibus, si citò adsit auxilium, in- terpositio artis scientifica, prospera est. DE HAEMORRHAGIA UTERI PUERPERA. 19 THERAPEIA. monoring Si in partubus prioribus, a haemorrhagia labo- rasset foemina, summa ope niti decet, ne recurrat fluxus. ong star enano Ad hoc efficiendum, foeminam cum fascia ac- cinctam esse suaderem, simul ac incipit partu- ritio, ut moderatè alvum comprimat; utile quo- que erit foeminam quietam servare, et a stimulis omnibus immunem. CONCLUSIO. Examinationes aequo frequentiores evitandae sunt; nam in nosocomiis obstetricis, ubi exami- nationes frequentes a discipulis instituuntur, pla- centae retentionem ob hanc causam occurrere saepe vidi. FINIS. Haemorrhagia ex ventriculi aut pulmonum vasibus inter pariendum, subinde occurrit. Si alacriter uterus se contrahat, interpositio artis non necesse est. 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