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The TaxisAuthor(s): Thomas HuntSource: Provincial Medical and Surgical Journal (1844-1852), Vol. 12, No. 3 (Feb. 9, 1848), pp.60-61Published by: BMJStable URL: http://www.jstor.org/stable/25500183 .

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60c~o THE-TAXIS IN STANGULATED HERNIA.

eighty-five cases in which there was extreme difficulty in

the labour, or where the child was dead, and inter.

ference necessary for the patient's safety, or for the full

completion of the delivery. In seventy-six out of

these eighty-five cases, data are afforded for ascertain

ing the duration of the labour.

Out of the seventy-six women, fourteen, or one in

every five and a half, died. The following table of

the results of these seventy-six cases of craniotomy, as

influenced by the previous duration of thelabour, affords direct evidence of the proposition which I have already stated, that the fatality attendant upou this, as upon the other allied forms of forced or artificial delivery, is regulated by the date or period of the labour at

which the operative interference is had recourse to.

TABLE VI.

Shewing the Maternal Mortality attendant upon 76

Craniotomy Operations, to be regulated by the previous

Degree of Duration of the Labour.

Date of Operation. Results to the Mothers.

Hours. In labours under 24 One out of 19 died

,, from 25 to 48 ,, 8 ,,

,, above 48 ., 3 ,,

The preceding body of evidence might easily be rendered more minute and detailed if it were necessary.

But I hold that it affords proofs sufficiently strong and

direct for our present enquiry. And the important

relations which it has to that inquiry amount to this,

that the facts adduced demonstrate

1st. That as a general law the amount and proportion of maternal and infantile deaths accompanying partu rition are regulated and modified by the length and

duration of the labour.

2nd. That the liability to various morbid obstetric

complications during and after delivery is modified

and regulated by the same law; and

3rd. That the mortality attendant upon obstetric

operations, such as the use of the forceps and crotchet, is also strictly modified and regulated by it,--operative

delivery being more and more fatal in proportion to the lateness in the course of the labour at which it is

adopted; and, on the other hand, less and less fatal in

proportion to the earliness in the course of the labour at which it is practised.

Now, the object of the present memoir is to propose that in cases of arrestment of the head at the brim of the pe\Wis, artificial delivery should be accomplished by turning, instead of being accomplished by the long forceps or craniztomy. And the operation which I thuswish to substitum has, as I have stated at the commencement of this section, this great and high advantage oer both the two others, for which I pro

pose it as an alternative, that, cceterisparibs, delivery

,by turning can, and must, as a general rule, be prac

tised far earlier in the labour, than delivery either by the long forceps or the crotchet; and in proportion as it is practised earlier, so far also will it be practised

with greater safety and greater success. A few remarks upon the time at which the employment of the long forceps or perforator is usually adopted will render this deduction more evident. In our next communication we shall consider this point, and the value of ausculta

tion in relation to operative delivery.

(To be continued.)

THE TAXIS. TO THE EDITOR OF THE PROVINCIAL MEDICAL AND

SURGICAL JOURNAL.

SIR, Your correspondent, "A Retired Surgeon of the

Irish College," (Provincial Journal, 1847, p. 682,) deserves the thanks of the profession both for the

courage with which he impugns the prevailing prac tice in the reduction of strangulated hernia, and

for the perseverance with which he persists in

calling attention to his own method, believing, as

he evidently does, that its general adoption. would

prevent much suffering and save many lives. His

sincerity and experience entitle his views to examina

nation, and I gladly take the opportunity which is

thus afforded, to call upon Hospital Surgeons, and

those especially who are connected with the Associa

tion, to consider whether the prevailing method of

using the taxis is the very best that can be adopted for

the purpose. It is much to be regretted that ourlecturers and

writers on surgery, too generally dwell with tedious minuteness on every step and stage of what is called

"the operation" for strangulated hernia,--i. e., the

operation with the knife, while the. far more difficult

and delicate operation without the knife, the taxis, is

passed over cursorily and carelessly as though its suc

cessful performance were dependent upon chance

rather than science and skill. " The moment that you find the tumour is hard, incompressible, not yielding in the slightest degree; that there is no gurgling, no

diminution of the convexity and hardness, not the

slightest appearance of getting the contents of the intestine

out, urge with all your eloquence the propriety of the

operation, for there is little danger if the operation be

performed at the proper time,-the greatest danger if it

be delayed after a certain time." (Med. Gaz., vol. xiij.,

p. 988.) These are the words of the lamented Sir

Charles Bell, and they constitute a fair sample of the

modern theory and practice of the London Hospitals,

The late Sir Astley Cooper, who has left so splendid a

contribution to the surgical anatomy of hernia, directs

that twe hernial tumour should be kneaded by a succes

sive motion of the finger and thumb, " until you at last

obtain a passage for a small portion of intestine or

omentum through the strictured part." (Cooper's,

Lectures.) I agree with your correspondent that much of this is erroneous in theory and inefficient if not

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AMPUTATION UNDER THE INFLUENCE OF CHLOROFORM. 61

mischievous in practice. The return of the hernia

does not occur in the way described, nor is it the

primary object of the taxis to " get the contents of

the intestine out."

Strangulated hernia is an accident involving con.

siderations, not mechanical only, but anatomical, phy

siological, and pathological. First, a portion of intes

tine is forced through the ring, together with a portion of omentum or mesentery, or both; the substance of

the latter fills up the ring. Compression upon the

veins is the next occurrence. The arteries, from their

tone and elasticity, continue to pour blood into the

tumour, which the veins cannot return, and the

tumour increases in size from venous congestion, fre

quently without any further advance of intestine

through the ring. This is the first stage of strangula tion. In the second stage active inflammation ensues.

In the third, sphacelus, produced either by the inten

sity of the inflammation, or more probably by the cir

culation in the tumour being at length wholly arrested

by the compression of the arteries at the ring. Reduction of a hernia by the taxis in the first stage of

strangulation is always practicable, though not always

easy, and sometimes impossible, if conducted on the

principles generally laid down. If the surgeon, sup

posing he must first return the portion of intestine

immediately engaged in the ring, pushes and pulls, or

kneads the tumour by a successive motion of the

finger and thumb, he will seldom succeed in a tight

case, even in this stage. And further, if he be intent

only on " getting the contents of the intestine out," he

will be apt to relinquish his efforts in disappointment after a short trial.

There is something to be done before either of these

are attempted. The tumour is full of distended veins, the

blood of which must first be returned very gently and

patiently; not by pushing and kneading, and thumbing, but by gentle equable compression on all sides of the

tumour, the abdominal and psoas muscles being pre

viously relaxed. Now, it is evident that the venous

blood, returning in obedience to the pressure of the sur

geon's hands, through a very small aperture, must needs

return slowly. If the tumour contain half a pint of

blood, which is returned at the somewhat rapid rate of

a drachm per minute, it will take sixty-four minutes to

return the whole. Here, then, is a full hour's work to be done, and in the case of a very large hernia, it has been known to occupy two hours and twenty minutes, and two pair of hands, to accomplish this first step in the reduction! What, then, do surgeons mean by trying the taxis for a quarter of an hour, or not at all,

operating on the moment, when they have the safe work of an hour or more before them ? So soon as the venous blood is returned in any quantity, the sensible diminution of the tumour shews the practitioner that his work is done. It is as well to keep up the pre are to the end, but the peristaltic action will soon do the

rest; the gas in the tumour rushes through the now more roomy ring, with the well-known gurgling noise; the iolid contents next; and, lastly, the fatty portion, (omentum, &c.,) follow the returning bowel through the ring.

In the next stage, (that of inflammation,) the same

practice carried out with yet more tenderness and

patience, will generally accomplish the same result.

In the third stage, (sphacelus,) the operation may be

necessary, but will rarely be successful. The symptoms of inflammation and sphacelus are sometimes obscured,

and it is not my object to lay down any rule in these

extreme cases, for or against the operation, but only to

suggest a more eligible and successful mode of employ

ing the taxis,-a mode which, after twenty-seven years

trial, I have never known to fail; although I am by no means prepared to say it never will fail, or that the

operation with the knife is never necessary. Your correspondent will perceive that I differ from

him in theory only by a shade, and that our practice is essentially the same. I see no objection (except

where approaching sphacelus is to be apprehended,) to

the application of cold, in conj unction with gentle, con

tinued, persevering pressure; but I should prefer a pre

vious trial of pressure, as an expedient often necessary on his own shewing, and in my experience always suc

cessful. Let no one, however, to whom these views

may be new, run away with the notion that the reduce

tion of a hernia, long strangulated, is supposed to be

an easy or simple operation. Any man with a steady

hand, who is familiar with the anatomy of hernia, can

opon the sac and divide the tendon. This is easily

enough accomplished,-it is but cutting the Gordian

knot; and yet, strange to say, a man who does this, often

gets more credit, even with his brethren, than be who,

superior in skill, can untie it! The operator, as he

is called, is handsomely paid, but all the reward

obtained by the man who reduces a hernia without

risking his patient's life, is, perhaps, the transient

gratitude of the sufferer, and a week's lumbago. I am, Sir,

Yours respectfully, THOMAS HUNT.

Herne Bay, December 18, 1847.

CASE OF AMPUTATION PERFORMED UNDER THE INFLUENCE OF CHLOROFORM.

By T. BERRY TORR, Esq., Surgeon, Barnstaple.

On Thursday afternoon last, (January 9th,) I was

requested by my friend Mr. Clarke, of Lynton, to meet him on the following morning, in consultation on the case of a very old man, 87 years of age,

named Thomas Bale, residing at a lone cottage at the higher part of the parish of Brendon, twenty five miles from this town, who had sustained a most severe compound fracture of the left leg, produced by one of those huge blocks of stone, (so common

in that locality,) weighing about a quarter of a ton,

having rolled down on him from a steep declivity,

and crushing his leg between it ad another stone of

considerable size.

On reaching the patient, in company with Mr. Clarke, on Friday, an examination of the injury too sadly

proved that the account of it which had been gifa me

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