ANEURISM OF THE LEFT EXTERNAL CAROTID ARTERY: SUCCESSFUL LIGATURE OF THE COMMON CAROTID

Let us consider the first class of cases. Since it is reasonable to suppose that in a case of strangulated hernia that has been operated upon, a part at least of the uneasiness dependent upon the intestinal function is immediately due to its restoration, we should in this class of cases theoretically be disposed to promote the action of the intestines, when it does not occur spontaneously, a short time after the constriction has been removed. Such practice seems the more reasonable, in that there can be no fear of aggravating inflammation which does not exist, and in that there is reason to believ-e that the expulsion of the accumulated ftecs is tantamoutnt to the exclusion of a possible, if not probable cause of inflammnuatioii. * In the second class of cases, the first part of the argument used above applies, b)ut not the second; for intlammation exists, and the question arises, whether the admiinistration of purgatives, theoretically indicated by the necessity of restoring the intestinal functions, may not be productive of. evil bv aggravating the inflammation. From what I have seen, however, thesc fears would not disquiet me. I think there is more chance of the progress of inflammation being checked by the expulsion of the irritating fTcces, and restoration of the gut to its function, than of its being .ag,rnavated by the stimulant action of the purgative. In the third class ofcases,in which the bowel is in moderate condition, but the peritoneum intentsely inflamed, it is reasonable to believe that the constipation, although in great mieasure dependent upon the atony which has resulted from long inactivity, is likewise due to the disturbance of innervation incident upon the inflamiiination. It seems hence prudent to respect the objections of those who allege that the inflammation may be aggravated by purgatives; but while antiphlogistics are being actively emlployed, there is no reason for objecting, if the bowels do not act, to enemata; the probabilities of their doingi good are much greater than those of their possible perniciousness. In the fourth class of cases (threateiiing gangrene of the intestine), iniasmuch as there is more to fear from the action of the intestines, though it be but moderate, thani from their inactivitry, though it be extreme, enema and puratives appear contra-indicated so long as there is reason to fear disor-anisation of the gut. From the foregoinig cDilsiderations flow three ruiles for practice, in cases in wvhich the operation of herniotomy is not followed by spontaneous action of the bowels. 1. When the condition of the gut is good, and there is little or no peritonitis, an oleaginous enema should be given an hour or two after the operation, and repeated after three or four hours in case of failure, or a purgative exhibited by the mouth. w 2. When the peritoneal inflammation is intense, even though the bowels be in fair condition, antiphlogistics must be perseveringly emploved; and though a simnple enema may be given in the first six hours, it is inadvisable to excite the action of the bowels until the next day, either by more active enemata or purgatives by the mouth. 3. In the case of mortification threatening the gut, the bowels should be kept quiet by opium, and purg-atives and enemata abstained from until the danger of perforation has passed. These rules promise to be faithful guides for practice, inasmuch as they are in conformity with sound doctrine, and, so far as I am aware, opposed by no facts; but the great rule is, to observe rigorously the symptoms of each lparticular case, to study its indications and aid nature with the lights which doctrine and practice reflect, and not to pretend to act according to systematic rules based upon speculations, in cases which present infinite varieties, according to the age and constitution of the patient; the duration, size, and position of the hernia; the degree and duration of the strangulation; the condition of the intestine; the presence or absence of inflammation; and other more or less important conditions. In truth, just as there is reason for dissenting from those who systematically oppose purgatives after herniotomy, there is reason for not placing implicit faith in the teaching of those who universally recommend them. If there be any class of cases in medicine and surgery-and there are many-in which systems are injurious, and in which each case requires to be studied of itself with the light of reason and experience, that class is precninently the one which comprises cases of strangulated hernia.