point with some of the best operators. M. Velpeau, Sir B. Brodie, Mr. Fergusson, and M. Bresciani de Borsa* are advocates for as small incisions as possible into the prostate being made, while the testimony of Cheselden, Martineau, John Bell, Samuel Cooper, and M. Malgaigne is in favour of a free incision. The last-mentioned surgeon thus speaks of the operation, after having described its varieties invented by different operators :

"After much study and comparison, I have come to the conclusion that but very little influence on the result of the operations, as regards the life or death of the patients, is to be attributed to the proceeding of operation. It is the pain and inflammation that kill the patients after lithotomy; and the most painful causes of these assuredly are the dragging, tearing, and bruising of the tissues; accidents inevitable in all the proceedings of perineal lithotomy, when the calcu lus surpasses the most moderate proportions, and which, when the patient does not sink under them, cause the most serious infirmities. I have seen several patients, who had been cut by the most skilful operators, the limits of the prostate being respected, who had lost all faculty of having erections and ejaculating, I saw one who, in addition to the absolute loss of his genital functions, could not retain his urine, and was obliged to keep his penis constantly squeezed by a constrictor. Double, triple, and quadruple incisions do not definitely augment the extent or elasticity of the external layers of the prostate (what does this mean?); and, by dividing it still more, they seem to expose it more also to be bruised in the passage of the calculus.

"In my opinion, there is only one way of rendering perineal lithotomy less dangerous, at least as regards the operation itself; it consists in following a precept entirely opposed to that which is generally laid down, viz. in dividing the prostate freely on one side beyond its limits; cutting the neck of the bladder and the cellular tissue, if the size of the stone necessitates it-in a word, making so free a passage for the stone that the wound may remain an incision, and not be complicated by contusions and lacerations. Ås for the external wound, it seems to me that it might be enlarged advantageously if required, by encroaching more or less on the right side of the raphe, to obviate the necessity of approaching too near the sciatic tuberosity. An external incision, bilateral if necessary, and a unilateral incision of the prostate, but with all the necessary extent, is the proceeding to which I give the preference, and which has already been adopted with success by several skilful lithotomists."-Malgaigne, p. 529.

Inguinal Hernia.-M. Malgaigne, speaking of Trusses, says that much consideration has led him to conclude-1. That three-quarters of the hernias are badly supported by any truss applied in the ordinary manner. 2. The English spring is far preferable to the old French one. 3. That moveable pads, in a great number of cases, have some real advantages over the fixed. 4. That in oblique inguinal hernia the pad should press on the course of the canal, and on the internal orifice, without touching the pubis, unless in some exceptional cases. 5. That in direct hernia the pad should be more voluminous, fixed, and resting on the pubis. 6. That hard pads are most suitable for compressing the canal, soft ones for direct hernia. 7. That it is much to be wished that surgeons would pay especial attention to this very important branch of our art, which has been too long

*See his interesting description of his mode of performing lithotomy, by which very great dilatability of the prostate is implied, Medico-Chir. Review, April,

1846.

1846.]

ON INGUINAL HERNIA.

429

left to bandagists. M. M. believes that, if trusses were better applied in adults, a cure might be effected in them as well as in children. "I have seen an inguinal hernia cured in one month in an old man 68 years of age, by complete obliteration of the canal obtained by means of simple compression." Mr. Liston, in like manner, says, " I have met with repeated instances in which a person, well-fitted with a truss, has been enabled, after a few months, to discontinue its use."

The Taxis.-The following rules for employing this, are laid down by the first-named writer.

"1. Evacuate the bladder to augment as much as possible the capacity of the belly. 2. Recommend your patient to breathe freely, without crying out or raising his head—in fact, not to make the least effort. 3. Make at the commencement but slight pressure, so that you may afterwards augment it by degrees, and continue it longer without bruising the hernia. 4. Return first the parts that last protruded. 5. Return them in the same direction they came out in. 6. In certain exceptional cases these general rules fail, and the patients themselves are in the habit of using some special way or means, to which it is better to have recourse. There are three principal proceedings.

66

(1). The surgeon seizes the hernia with one hand, in such a way that the palm of the hand presses on the base, and the fingers all around the neck of the tumour. He raises it in this way, and pushes it in the direction of the ring, compressing with his fingers the part next the ring, so as to diminish it to a suitable diameter. (2). He embraces the hernia with one hand or both (according to its volume), exactly applying his fingers on its entire surface, so that if possible no portion may remain uncovered, and presses all parts of the circumference of the tumour towards the centre. The efficacy of this pressure is augmented by, as it were, drawing the tumour out from the belly, and carrying it from one side to the other, compressing it with your fingers, so as to unfold the portion of the intestine contained in the ring, and cause the wind and fæces that engorge the hernia to re-enter the belly. (3). He leaves free the bulk of the tumour, but applies one or two fingers close to the ring on the sides of the hernial sac, and pushes thus across the ring the part immediately next to it. When you have in this way returned a small portion, keep it back with the fingers that pushed it in, and push up another, but with the fingers of the other hand, and so on. It often happens that when the strangulated portion, which formed a sort of plug, is returned, the rest follows easily.

*

*

*

*

*

*

*

*

It remains for us to make known three other modifications which seem to us to deserve serious attention. M. Ribes takes a mattress, folded and doubled up, so that the edge of the superior fold passes a little beyond the edge of the inferior one, and the surface of the mattress describes a very oblique plane: one or two bolsters are put under the doubled end of the mattress, to increase this obliquity, and the whole is covered with a sheet. This done, the patient is placed on the bed, with his buttocks on the edge of the mattress, and his thighs stretched out and in a line with his belly, and with his pelvis much elevated, and his diaphragmatic region as low as possible. His head must be supported with a pillow, and he must keep in this position all the time required. Then the taxis is tried; and, between each attempt, a bladder of ice kept on the tumour. Amussat gives the patient a similar position, but, in addition, he flexes the thighs to relax the abdominal muscles, and inclines the entire body to the side opposite the hernia; and, lastly, while he is performing the taxis, an assistant keeps up a gentle traction on the belly, trying to draw it to the healthy side, and raises from time to time the parietes of the abdomen, slightly pinching up the skin. But, what is more important, M. Amussat continues the taxis during two, three, or four hours, or even more, and has, by these means, reduced hernias that seemed only No. 106.

29

curable by operation. It is an admirable method, when you are sure the intestine is free from gangrene; but one to which recourse must not be had when the duration of the strangulation, or the rapid progress of unfavourable symptoms, gives a reason to dread this fatal termination. Lastly, M. Koehler applies a cupping-glass on the hernia itself, to draw outside a large quantity of the intestine, and especially disengage the strangulated portion. This proceeding has seemed to him to greatly facilitate the reduction.-Malgaigne, pp. 421-3.

The Operation. After describing the procedures of other surgeons, M. Malgaigne adverts to his own.

"I make my incision, not on the sac and scrotum, but on the place where the strangulation seems to be situated, prolonging it upwards and downwards to the extent required by the embonpoint of the subject, and the size of the hernia. All the tissues are divided in the same way down to the peritoneum; and, as we thus expose and lay bare the vessels, we put them aside, and have nothing to fear from them. If you find the strangulation is caused by a fibrous opening, you need not open the sac, but reduce the hernia. If not, the neck is divided from without inwards, carefully and gently; or, if the stricture appears very strong, you make a small incision in the peritoneum, either above or below the neck, which you then raise upon a director and divide.

"In this proceeding I find the great advantage of being able to see everything as I go on. 2. I reach the strangulation by the shortest way, and with the least possible incision. 3. I leave untouched the scrotum and sac, and consequently am not troubled with the cicatrization and suppuration of a wound, at all events useless. I lately performed it for a large scrotal hernia; the neck of which was situated on a level with the abdominal ring, the sac, which I had respected, though I opened its neck, filled in the first few days with a certain quantity of liquid, which was reabsorbed as the inflammation of the superior wound went down, and the patient was cured without accidents."-P. 429.

Operation without opening the Sac.-Mr. Liston thus states his opinion upon this important point of practice.

"He will thus cut the resisting tissues to a sufficient extent, in a line parallel to the linea alba: the reduction of the contents of the sac may then be attempted; and, if it prove successful, one great danger of the operation, that arising from exposure of the peritoneal sac, the lowering of its temperature, and the consequent shock upon the system, is avoided. But, even in favourable cases of this variety of hernial protrusion, there are difficulties to be encountered in accomplishing this most desirable object; the constriction is caused by a condensed cellular and fibrous tissue immediately investing, and incorporated with, the serous cyst. The stricture may, in fact, be said to exist very often in the neck of the sac itself, and this must be cut before the contents can possibly be returned. In many cases, the reduction is impeded by adhesions, and by entanglement with omentum again, when the strangulation has existed any considerable time, it is desirable to ascertain the precise condition of the protruded parts, and to consider, after careful and actual inspection, whether they should be returned or not.” -P. 551.

When treating of Femoral Hernia, he thus expresses himself :

"He may now try to reduce the contents of the sac by pressure: taking especial care not to push back sac and all-rather a serious accident. This plan was advocated strongly, long ago, by Petit and Monro secundus, and has lately been

1846.]

SIMON ON MEDICAL DEONTOLOGY.

431

revived and practised by Mr. Key, Mr. B. Cooper, Mr. Luke, and others. I have fortunately succeeded in effecting this object in a considerable number of instances, within these few years: and it is a proceeding which I should most strenuously advise the adoption of, when nothing contra-indicates it. The attempt can do no harm it causes little or no delay, and, if it is not successful, the sac, after all, is opened, and the operation completed. If it does prove successful, the surgeon's mind is relieved of an uncommon load of anxiety."-P. 558.

Dilatability of the Vagina.-M. Malgaigne states, in the following passage, the varying degree of this according to age :

"The dimensions of the vaginal orifice are very variable. It is important to know that in young women it is exceedingly dilatable; it is less yielding in adults; and after the cessation of the menses its rigidity goes on increasing, so that, at a very advanced age, instead of feeling at this orifice a supple ring, yielding under the fingers, we find it hard and splitting at the slightest effort made at overcoming its resistance. It then sometimes scarcely admits the little finger, and the vagina itself, instead of offering its usual rugæ, presents polished walls and a very constricted capacity. The result is that, in young women, however narrow the orifice may appear, we may confidently rely on its dilatability; that, in adults, we must not place so much reliance on it, and must use a speculum not much larger than the apparent capacity of the orifice; and, lastly, that at a later period, we should be more reserved in employing the speculum at all; proceed with gentleness and caution, in order to avoid lacerations, which cicatrize with difficulty; and use only a very small speculum. Lisfranc has found it necessary to prepare the parts, during eight or ten days, by dilating them with prepared sponge."-P. 543.

We must here conclude our extracts, and can only wish a continuance of success to two such excellent works.

DEONTOLOGIE MEDICALE, OU DES DEVOIRS ET DES DROITS DES MEDECINS, DANS L'ETAT ACTUEL DE LA CIVILISATION. Par le Docteur Max. Simon. Octave, pp. 567. Paris, 1845. Bailliere.

Medical Deontology, or the Duties and Rights of Medical Men in the present State of Civilization. By Dr. Max. Simon.

It was only in our last number that the following passage occurs at the close of an article upon Military Punishments: "Surely there is no occupation, in which medical men can more profitably fulfill their beneficent mission, than in using all their professional influence and authority to plead the cause of the suffering and oppressed against the heartless neglect or tyrannical severity of irresponsible taskmasters. Of recent years, the fruits of enlightened medical philanthropy have been gloriously displayed in the changes already effected in our prisons and lunatic asylums, &c., and in the improved general economic treatment of our pauper population. May the same good spirit continue to animate every member of the profession, in whatever sphere he may be placed! It is thus only that

our calling may justly claim to itself the proud distinction, that has been assigned to it by the eloquent orator of antiquity, of being an art almost divine.'"

*

When we wrote these words, we did not expect to have so early an opportunity of directing the attention of our readers to the general question of Medical Deontology, or, in other words, that of the Rights and Duties of our profession. Dr. Simon's work had indeed been published several months before; but it is only within the last few weeks that it has been brought under our notice. The perusal of it, we rejoice to say, has given us very great satisfaction. Everywhere it breathes a spirit of high-toned moral feeling, and dignified independence of thought. May its influence be felt and appreciated by his countrymen! To us it will be a source of very sincere pleasure if the extracts, which we propose to select from its pages, have the effect of introducing it to the notice of the British medical public, and of its merits being acknowledged by our press. Much honour

is due to the literature of France that, amid the general apathy and indifference of medical men of all countries, in the present century, to the intimate connection between their very responsible calling and the exercise of the highest social virtues, one of her sons has not been ashamed to step forward with the bold avowal and manly vindication of principles, which, although they may be regarded as Utopian or Puritanical by many, cannot but actuate every truly great and good physician in his intercourse with the sick and afflicted of mankind. He will ever remember that he has other duties, besides those of studying the physical effects of disease, or of prescribing remedies for its relief; great and pressing duties which he owes to himself, to society, and to his God. It is the sin of the present age to view everything with a sort of materialising and mercantile spirit, to estimate the value of an object only by its immediate results, and by the effects which it sensibly and visibly produces. It is an age of facts rather than of principles, of experiment rather than of reflection. How strikingly is this the case in all that appertains to the science and art of Medicine. Every year, nay, every month or every week, brings forward its new remedy, its novel discovery. The journals teem with practical facts-so, at least, are they supposed to be, and so are they termed. It is almost surprising that anything now remains to be found out, considering the abundance of successful or infallible remedies or modes of treatment for almost every disease. Then again in Physiology, every thing is determined by positive experiments on living animals; and, when so determined, it is asked how can the conclusions, so derived, fail to be correct? It may be so; but we should like to be told, how comes it to pass that there is so much discrepancy and downright contrariety of statements and conclusions among different physiological observers? The question is puzzling; where is the solution to be found? What is to be done? we might presume to answer, we should say; watch more, work less; interrogate nature by long and patient observation, rather than by rough force or cruel compulsion. Are we not told that not even a sparrow falls

If

* This term was first used by Bentham to denote the science of Ethics. It is derived from dsov quod decet, æquum and λoyos sermo.