ON

PETIT'S OPERATION

FOR THE RELIEF OF

STRANGULATED HERNIA.

BY JAMES LUKE,

SURGEON TO THE London and sT. LUKE'S HOSPITALS, AND LECTURER on

SURGERY AT THE LONDON HOSPITAL SCHOOL OF MEDICINE.

COMMUNICATED BY THE PResident.

Received Feb. 16th-Read Feb. 22nd, 1848.

It has been remarked that the comparative value of the operation for the relief of strangulated hernia, as recommended by Petit, without opening the hernial sac, must be determined ultimately by an appeal to experience. However true the remark, and however desirable it may be to arrive at just conclusions, many difficulties arise in the course of inquiry, which do not present themselves upon a first view of the subject. Of these, the impossibility of obtaining parallel cases for comparison appears to present an almost insurmountable obstacle to a perfectly satisfactory result.

This difficulty, however, may in great measure be overcome by the comparison of large numbers of cases. But by this mode of proceeding, difficulties of another kind are created, which time and numerous opportunities alone can fully obviate. Cases collected in publications from the separate experience of many surgeons seem wholly insufficient, and are almost worthless unless they embrace the entire of such experience. It must be evident that the selection of cases from amongst others of the same kind, which for various reasons are withheld from publication, must necessarily yield

a false colouring to the experience it is intended they shall represent; and although they may in themselves be true, they do not represent the whole truth, and consequently are extremely unsafe for the purposes of just comparison.

The experience of Petit's operation hitherto published eems wholly to be of this character. The few cases already collected have been culled from many sources, whence it is highly probable that more extensive details might have been furnished, with conclusions more worthy to be considered as the fruits of experience.

In offering the present paper to the Society, I have endeavoured as much as possible to avoid this source of fallacy, by rendering up for its consideration the whole of the experience which I possess upon the subject of which it treats. It will, however, be proper to mention that I have not deemed it necessary to state the result of my experience of the operation for the relief of strangulated hernia as ordinarily performed by opening the hernial sac. Indeed, were I so disposed, I have not at hand the means necessary for the purpose, as some years have elapsed since I abandoned the ordinary operation as an ordinary practice. It will perhaps be sufficient for the purposes of comparison to call attention to a few details of the ordinary operation which have been published from the experience of others, but not open to the objections above stated. From these we learn the serious results and high rates of mortality which have usually followed this common course of proceeding, and are powerfully impressed with an idea of the necessity of seeking means for its diminution.

M. Textor states that, of fifty-six cases of strangulated hernia subjected to operation at Wurtzburg, between 1816 and 1842, twenty-four died, or nearly one-half.

M. Malgaigne states that of 220 cases subjected to operation in the Parisian Hospitals, between 1836 and 1840, 133 died, or considerably more than one-half.

Of fifteen cases of operation published by Mr. South, six died, or one in two-and-a-half.

Of cases published in the British Journals, I some time since ascertained that one-half died.

Of sixty-five cases subjected to the operation of opening the hernial sac, in the London Hospital, twenty-two died, or rather more than one-third of the whole number.

The obvious tendency of such details is to disincline surgeons from undertaking an operation so apparently fatal, until every effort likely to render it unnecessary by a successful taxis has been exhausted. Procrastination and delay is the too common effect. The results of the taxis also favour protracted efforts; and thus, the mortality of the operation, by deterring from its performance, on the one hand,-and successful taxis, by inviting protracted trials, on the other, -lead equally to delay and the loss of much valuable time. Mr. King states that, of forty patients relieved by taxis, four died.

M. Textor states that, of 114 patients relieved by taxis, nine died.

Of 293 patients admitted into the London Hospital for strangulated hernia, between 1842 and 1847, 206 were relieved by taxis: amongst these patients there is not any death recorded.

We may, therefore, conclude, that when the taxis is performed successfully, the attendant danger to the patient is not very great, and persevering efforts for the attainment of so desirable a result appear to be a natural consequence. Conclusive and legitimate as the inferences appear from the foregoing statement, there are fallacies beneath them which it is desirable should be corrected, lest they encourage a practice more fatal even than that which I have stated as following the ordinary operation when ultimately appealed to.

I am not aware that at present any data exist adequate to remove those fallacies in a perfectly satisfactory manner. To do so, it is necessary that the general mortality of all cases treated by taxis and by operation should be stated conjointly, and a comparison instituted between the practice of protracted attempts to secure a successful taxis, and of

securing an early relief by any means to constricted parts, either by taxis or by operation. It is possible (although I think not probable) that the augmentation of the mortality of the operation, when deferred, is neutralized in the general results by the increased security which a successful taxis yields to the patient, even when protracted, and that what is lost on the one hand is gained on the other in the general average of mortality. There can be little doubt, however, that the mortality succeeding the operation alone is greatly increased by delay in its performance. Thus of sixty-nine patients operated on at the London Hospital or by myself, before the expiration of forty-eight hours from the commencement of strangulation, twelve died. Of thirty-eight patients operated on after the expiration of forty-eight hours, fifteen died. Of thirteen patients in whom the strangulation was of doubtful duration, six died.

That the operation itself as ordinarily performed, abstractedly from all considerations of visceral lesion by constriction, is in some degree dangerous, must be admitted. That the danger is also increased by the necessary exposure and immediate manipulation of parts so important to life, (especially when already the subject of inflammation,) is likewise true. Thence might partly arise the reluctance to have recourse to operation; and it appears likely that if the taxis could be accomplished even by an operation, without such exposure and manipulation, the reluctance would be in some measure, if not wholly, removed, and an earlier appeal to such operation might generally be expected as the result, provided no new dangers arise from the proceeding.

Such is indeed the scope of Petit's operation, which, by leaving the hernial sac unopened, causes a very close assimilation to the taxis as ordinarily performed; and this has already been shown to be attended by a very moderate amount of danger. The arguments, à priori, in favour of Petit's operation have already been stated by Mr. Key, in an excellent memoir on the subject, published some time since. It will consequently be unnecessary to repeat them in a paper in