traction from within, and in it certain cases?a proposal which advocated Professor ire of Spence very conexcited the siderably. Mr. Tait appears to have been first
practised
burgh,
led to this practice in dealing with cases of abdominal tumour, complicated as these often are by hernia. He supplemented the abdominal operation by pulling the hernial contents out of the
the neck from within ; and he that has had evidence many of the cases so treated have been radically cured. He has also practised the operation for incarceration and strangusac, and
qdiqat teqtfi),
?[tq Jmlisnt
NOVEMBER, 1891. THE TREATMENT OF HERNIA BY MEDIAN ABDOMINAL SECTION.
Mr. Lawson Tait is
nothing,
if he is not
original and adventurous, and his proposal to treat hernial protrusions by abdominal section,
traction of the hernial contents from within and closure of the hernial aperture by internal stitching is both ingenious and bold. This pro-
posal was originally put published in the British
forward in
a
paper Medical Journal in September 1883, and it formed the subject of a paper read at the last Annual Meeting of the British Medical Association, in which the
grounds rests are
rise to
theory and experience on which it systematically stated. This paper gave of
a
very
interesting discussion,
in which
Messrs. Keetley, Jordan, Lloyd, Barling Greg Smith, Bennett May, Maunsell, O'Callaghan, Stanley Boyd, Bishop, Manley, and Ward Cousins took part. The Mr. Tait's
proposal is very in this discussion. The instructively stated idea of pulling from within the contents of a case
for and
against
rupture irreducible by taxis,
must
have
oc-
curred to surgeons from the earliest times; but they were deterred by the dread of opening
the peritoneal cavity?a dread which has only disappeared within the last quarter of a cenif indeed it has altogether vanished even now. It is true that opening the sac amounts actually to opening the peritoneum, and that
tury,
reduction by manipulation involves handling the abdominal contents and sometimes pretty roughly j bnt there was always the hope in performing
herniotomy of reducing the contents after dividing the stricture without opening the sac, which
m
the old
Many
days
meant
a
years ago Professor
much safer
operation. Annandale, of Edin-
stitching up
lation, and apparently with uniform and striking success. He attaches great importance to preserving the tendinous ring outside of the neck of the sac intact, and strengthening it by inserting loops causing cicatricial thickening, and he does not consider the existence of omental adhesions prohibitive. On the contrary, they yield readily to traction, and as the bleeding is omental, it can readily be stopped. He also claims that
a
more correct
state of the reduced contents
diagnosis
can
be
of the
made,
reduction en bloc rendered impossible; and in cases of gangrene from strangulation, he siders that the
suprapubic
situation for
artificial
an
wound is
anus
and even con-
a
better
than the
groin.
Dr. Maunsell, of New Zealand, contends that such operations as colotomy, colectomy, enterotomy or enterectomy, if required, can be more
easily performed through an abdominal wound than an enlarged hernial aperture. The objections urged against Mr. Tait's proposal may be summarised
follows:?It is unnecessary in The procedures for now resorted to are easy and safe,
as
of reducible hernia.
cases
radical
cure
and leave
ring is, weakening
The tendinous
to be desired.
nothing doubt,
divided in
no
some cases,
thereby
that part of the abdominal wall, but this is more than compensated by subsequent stitching. The sac is left, and probably a hollow
neck, and firm, there
at its not
against
this
if the occlusion of the neck is is
tendency
a
objection
Tait
The contents cannot
to
recurrence;
his
places always be
experience. by
returned
traction from within in consequence of matting adhesions, &c. Tait and Maunsell say they can, and that if
they can't,
there is
no reason
why second incision should not be made into There may be complications in the the sac. a
sac?hour which it
glass condition, double is
desirable
to
sac,
expose
bands, &c., for proper
344
INDIAN MEDICAL GAZETTE. The fluid contents
management. be of
may and if
permitted
cavity,
may
sue
poisonous kind; general peritoneal extensive and danger-
to enter the
rise to
The intestine may be adherent ulcerated and torn in the act of
peritonitis.
ous
diseased
or
give
of the
and
irritating1
an
or
The gut may be gangrenous, and give under traction, discharging its contents way Two other objecinto the peritoneal cavity.
traction.
tions
occur to
us
in addition to
these, namely,
that conservative adhesions may have been set up at the neck of the sac in cases long stran-
gulated, and that it is undesirable in the last degree to disrupt these ; and that irreducibility does
always or solely depend upon conbut striction, upon impaction alone or in addicontents are held in the sac like the that eo tion, not
button in its hole, which simple traction There are also cases in which never undo. cajcum slips down without a sac or with a
a
partial
sac
covering,
whether reduction
by
internal
while
can
traction.
can
the
only
and it is very doubtful be effected in such cases Most
of the
opposing Tait's proposal
speakers,
as a
general practice, allowed that there were cases?umbilical, obturator, and femoral hernia} more especially? in which it was the better procedure, and both Tait and Maunsell acknowledged that the plan of abdominal section and traction from within
was not
applicable
remains, therefore, of
cases to
adapted; accepted
which
to
all
cases.
It still
to define
one or
accurately the class other operation is best
and meantime Tait's as a
feasible and
proposal must be practicable one, and
suited to some, if not to many cases of hernia; the precise extent and range of its application
remaining experience
for the present and uncertain.
pending further
TNov. 1891.
practised
burgh,
led to this practice in dealing with cases of abdominal tumour, complicated as these often are by hernia. He supplemented the abdominal operation by pulling the hernial contents out of the
the neck from within ; and he that has had evidence many of the cases so treated have been radically cured. He has also practised the operation for incarceration and strangusac, and
qdiqat teqtfi),
?[tq Jmlisnt
NOVEMBER, 1891. THE TREATMENT OF HERNIA BY MEDIAN ABDOMINAL SECTION.
Mr. Lawson Tait is
nothing,
if he is not
original and adventurous, and his proposal to treat hernial protrusions by abdominal section,
traction of the hernial contents from within and closure of the hernial aperture by internal stitching is both ingenious and bold. This pro-
posal was originally put published in the British
forward in
a
paper Medical Journal in September 1883, and it formed the subject of a paper read at the last Annual Meeting of the British Medical Association, in which the
grounds rests are
rise to
theory and experience on which it systematically stated. This paper gave of
a
very
interesting discussion,
in which
Messrs. Keetley, Jordan, Lloyd, Barling Greg Smith, Bennett May, Maunsell, O'Callaghan, Stanley Boyd, Bishop, Manley, and Ward Cousins took part. The Mr. Tait's
proposal is very in this discussion. The instructively stated idea of pulling from within the contents of a case
for and
against
rupture irreducible by taxis,
must
have
oc-
curred to surgeons from the earliest times; but they were deterred by the dread of opening
the peritoneal cavity?a dread which has only disappeared within the last quarter of a cenif indeed it has altogether vanished even now. It is true that opening the sac amounts actually to opening the peritoneum, and that
tury,
reduction by manipulation involves handling the abdominal contents and sometimes pretty roughly j bnt there was always the hope in performing
herniotomy of reducing the contents after dividing the stricture without opening the sac, which
m
the old
Many
days
meant
a
years ago Professor
much safer
operation. Annandale, of Edin-
stitching up
lation, and apparently with uniform and striking success. He attaches great importance to preserving the tendinous ring outside of the neck of the sac intact, and strengthening it by inserting loops causing cicatricial thickening, and he does not consider the existence of omental adhesions prohibitive. On the contrary, they yield readily to traction, and as the bleeding is omental, it can readily be stopped. He also claims that
a
more correct
state of the reduced contents
diagnosis
can
be
of the
made,
reduction en bloc rendered impossible; and in cases of gangrene from strangulation, he siders that the
suprapubic
situation for
artificial
an
wound is
anus
and even con-
a
better
than the
groin.
Dr. Maunsell, of New Zealand, contends that such operations as colotomy, colectomy, enterotomy or enterectomy, if required, can be more
easily performed through an abdominal wound than an enlarged hernial aperture. The objections urged against Mr. Tait's proposal may be summarised
follows:?It is unnecessary in The procedures for now resorted to are easy and safe,
as
of reducible hernia.
cases
radical
cure
and leave
ring is, weakening
The tendinous
to be desired.
nothing doubt,
divided in
no
some cases,
thereby
that part of the abdominal wall, but this is more than compensated by subsequent stitching. The sac is left, and probably a hollow
neck, and firm, there
at its not
against
this
if the occlusion of the neck is is
tendency
a
objection
Tait
The contents cannot
to
recurrence;
his
places always be
experience. by
returned
traction from within in consequence of matting adhesions, &c. Tait and Maunsell say they can, and that if
they can't,
there is
no reason
why second incision should not be made into There may be complications in the the sac. a
sac?hour which it
glass condition, double is
desirable
to
sac,
expose
bands, &c., for proper
344
INDIAN MEDICAL GAZETTE. The fluid contents
management. be of
may and if
permitted
cavity,
may
sue
poisonous kind; general peritoneal extensive and danger-
to enter the
rise to
The intestine may be adherent ulcerated and torn in the act of
peritonitis.
ous
diseased
or
give
of the
and
irritating1
an
or
The gut may be gangrenous, and give under traction, discharging its contents way Two other objecinto the peritoneal cavity.
traction.
tions
occur to
us
in addition to
these, namely,
that conservative adhesions may have been set up at the neck of the sac in cases long stran-
gulated, and that it is undesirable in the last degree to disrupt these ; and that irreducibility does
always or solely depend upon conbut striction, upon impaction alone or in addicontents are held in the sac like the that eo tion, not
button in its hole, which simple traction There are also cases in which never undo. cajcum slips down without a sac or with a
a
partial
sac
covering,
whether reduction
by
internal
while
can
traction.
can
the
only
and it is very doubtful be effected in such cases Most
of the
opposing Tait's proposal
speakers,
as a
general practice, allowed that there were cases?umbilical, obturator, and femoral hernia} more especially? in which it was the better procedure, and both Tait and Maunsell acknowledged that the plan of abdominal section and traction from within
was not
applicable
remains, therefore, of
cases to
adapted; accepted
which
to
all
cases.
It still
to define
one or
accurately the class other operation is best
and meantime Tait's as a
feasible and
proposal must be practicable one, and
suited to some, if not to many cases of hernia; the precise extent and range of its application
remaining experience
for the present and uncertain.
pending further
TNov. 1891.
