MEMOIR
ON THE
EXTERNAL DIVISION OF THE STRICTURE
IN
STRANGULATED HERNIA.
BY C. ASTON KEY.

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#3072


A
MEMOIR
ON THE
ADVANTAGES AND PRACTICABILITY OF DIVIDING
THE STRICTURE IN
STRANGULATED HERNIA
ON THE OUTSIDE OF THE SAC.
WITH CASES AND DRAWINGS.
By C. ASTON KEY,
SENIOR SURGEON TO GUY'S HOSPITAL, AND LECTURER ON
SURGERY, ETC.
LONDON:
PRINTED FOR
LONGMAN, REES, ORME, BROWN, GREEN, & LONGMAN,
PATERNOSTER-ROW.
1833.

TAUB
RD
621
•K48
ALMICH GETATUONASTE
LONDON:
Printed by A. SPOTTISWOODE,
New-Street-Square.

ΤΟ
HIS COLLEAGUES,
THE PHYSICIANS AND SURGEONS
OF
GUY'S HOSPITAL,
THE AUTHOR BEGS TO DEDICATE THESE PAGES,
AS
A MARK OF HIS SINCERE RESPECT
ST. HELEN'S PLACE,
May 1. 1833.
AND ESTEEM.
A 2


PREFACE.
மன்
THE operation of dividing the stricture
of a hernia on the outside of the sac is
not new: it has occasionally been per-
formed, but at very distant intervals.
From the defective state of pathological
Anatomy, the steps of the operation have
been so imperfectly detailed, that it has
met with but few admirers, and still fewer
imitators.
More than a quarter of a century has
elapsed since the publication of Sir Astley
Cooper's discoveries in the anatomy of
inguinal and femoral Hernia. Yet, not-
withstanding this vast accession to our
knowledge, the operation continues much
the same as it was fifty years ago; while
the records of surgery afford ample evi-

vi
PREFACE.
dence that improvement in this depart-
ment of operative surgery is much wanted.
Upon his correct anatomical views is
founded the operation which I have here
advocated.
Having found the operation less difficult
of execution than I had anticipated, and
that its success realised all I had expected,
I have brought it forward in the following
monograph, in the hope of making its
advantages generally known, and, probably,
more generally adopted.
be wat tud de

CONTENTS.
Observations on the Danger attending the Oper-
ation for Strangulated Hernia
Historical Sketch of the Operation of dividing the
Stricture without including the Sac
1
Advantages of this Operation
Objections to it considered
Femoral Hernia
29
47
78
The Author's Experience of the Operation
-116/23
- 129
Inguinal Hernia
Umbilical Hernia
- 146
- 150
DRAWINGS, WITH EXPLANATIONS.


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THE fatality that often attends the usual
mode of operating for strangulated hernia
must have been a subject of deep consi-
deration and regret to every surgeon who
bestows much thought on the results of his
practice, and who endeavours to make his
art subservient to its proper object,-the
prevention of suffering and the preservation
of life. Oftentimes must he have deplored
the necessity of having recourse to an oper-
ation that, under some circumstances, holds
out so slender a chance of success; and not
unfrequently has his duty compelled him
to perform it with the conviction that,
while it afforded the only hope of relieving
the intestine from impending gangrene,
B

2
DANGER OF THE OPERATION
it would almost certainly lead to the de-
struction of the patient.
That this is not an exaggerated feeling
of apprehension as to the dangers attending
the operation for strangulated hernia, the
records of large hospitals and the memo-
randa of private practice, if candidly stated,
will abundantly testify; and it cannot but
strike the reader of the periodical publica-
tions, that they alone furnish sufficient evi-
dence of its mortality, in the numerous post-
mortem examinations, compared with the
number of successful cases detailed in these
works. The danger of the operation, it is
true, is by no means the same, under all
the circumstances attending strangulated
hernia; and in some cases, when the oper-
ation is performed early, before untoward
symptoms have supervened, it is usually
attended with a fair prospect of success.
But in estimating the risk of an operation,
we must not separate the favourable from
the unfavourable cases; we should form
our judgment upon the nature and the
issue of the aggregate cases that present
themselves to surgeons in the ordinary

FOR STRANGULATED HERNIA.
3
course of practice; and it is equally im-
material to the argument, should it be
urged, that the operation is successful in the
hands of one surgeon, if in the practice of
another an equal share of skill in the oper-
ation, and of discernment in the after-
treatment of the case, fails to ensure the
same degree of success. It has lately hap-
pened to me to witness a series of unsuc-
cessful operations for hernia, in which every
thing was done that skill could effect, or
the best judgment could suggest, and in
which, from the previous condition of the
patients, well-founded expectation was en-
tertained of their doing well after the return
of the prolapsed parts; but in each peri-
tonitis insidiously came on, and, within a
few days, prostrated the patient's powers
beyond the chance of recovery.
The conviction of the frequent fatality
of operations for hernia is slowly and
with difficulty impressed upon a surgeon's
mind. His sphere of observation may,
perhaps, be limited, and the few cases
that have occurred in his practice, or come
under his notice, may have been attended
peiloenco

4
ADVANTAGE OF
with more than an ordinary share of suc-
cess; or, if his practice be confined to
private patients, and he is fortunate
enough, and, it may be added, wise enough,
to operate before inflammatory symptoms
show themselves, he will save the majority
of his cases, and, naturally enough, will be
slow to believe that the operation is sur-
rounded with so much danger as is here
stated. I am free to confess that, among
private patients, the average success of the
operation is much greater, for reasons
which I shall take occasion to advert to,
than among the same number of cases in
the practice of an hospital.
But even
should he have had a more extensive field
of observation, and have witnessed a large
proportion of fatal cases, he is disposed to
attribute the failure to the peritonitis es-
tablished before the operation, or to the
previously inflamed state of the bowel, or
to any cause but the additional mischief
inflicted by the operation. Or should
he be inclined to consider the operation as
the cause of the destructive inflammation,
he regards it as an extraordinary occur-
rence, consoling himself with the reflection

AN EARLY OPERATION.
5
that it is an exception to the general result
of his cases, and that success is not always
to be obtained.
Unfortunately, a surgeon who, from ex-
perience, is aware of the great risk to which
the operation exposes his patient, is compel-
led either to shrink from his duty, and trust
to the effect of remedies which past ex-
perience has proved to be unavailing, or to
perform an operation which, under existing
circumstances, instead of giving relief, will
only tend to aggravate the inflammation.
It may be contended, that the operation,
when performed early, is, according to the
testimony of the most experienced surgeons,
generally successful. Mr. Hey emphatically
observes, "I have now performed the opera-
tion forty times, and have often had occasion
to lament that I had performed it too late,
but never that I had performed it too soon."
And, therefore, it may be asked, Why
should the operation be deferred until in-
flammation has taken place? There are
various causes of delay that do not rest
with the surgeon. In some instances, the ex-
istence of the tumour is undiscovered until
gobating B
ang в 3 ei ylleisenze) veleb

6
EARLY OPERATION
symptoms of inflammation begin to show
themselves, and lead the surgeon to suspect
a hernia: this is especially the case in
femoral hernia. Concealment of the tumour
is not unfrequently practised by females,
either from motives of delicacy, or from
not connecting the tumour and the symp-
toms as cause and effect. In other forms
of rupture, as in a sudden inguinal descent,
attended with immediate strangulation, the
lapse of a few hours employed in using the
means of reduction will occasionally be suc-
ceeded by the setting in of urgent in-
flammation of the peritoneum. Sometimes
intestinal derangement is the precursor of
a protrusion into an old hernial sac, and
may even lead to its occurrence, as in um-
bilical hernia. In this kind of incarceration,
the symptoms depend, perhaps, more on a
loaded state of the bowels and impeded
peristaltic action, than on an obstructed
state of the circulation: tenderness and
tension of the abdomen are its earliest ac-
companiments, and evince the great pre-
disposition to inflammation that attends
this species of hernia. Other causes of
delay (especially in the practice of an hos-

OFTEN IMPOSSIBLE.
7
pital) might be enumerated, that tend to
defer the operation until inflammation
comes on; so that, notwithstanding the
excellence of the precept, that the oper-
ation cannot be performed too soon, cases
will occur in which the surgeon, however
prompt he may be, will have to operate
under all the disadvantages of peritoneal
inflammation.
It will no doubt be readily admitted,
that the operation of opening the hernial
sac and dividing its neck, when performed
during the existence of inflammation, tends
to increase the inflammatory action, and
that, in this condition of the abdominal
contents, the operation is attended with no
small degree of danger; but some may be
not equally disposed to admit, that an in-
cision made into a serous cavity not pre-
viously inflamed is likely to be productive
of a fatal degree of inflammation. I am by
no means desirous of representing a wound
of a healthy serous membrane as an injury
of a highly dangerous nature, and as uni-
versally followed by wide-spreading inflam-
mation. Wounds of the abdominal cavity
B 4

8
WOUNDS OF THE PERITONEUM,
and of the pleura, that have come under
my observation, have frequently healed by
adhesion, without the presence of an alarm-
ing symptom; and, as the ingenious author*
of the Observations on Abdominal Surgery
has shown, incisions into the peritoneum
may be made without that immediate risk
of inflammation which was formerly sup-
posed to attend such wounds. The Cæsarean
operation, the operation of removing ova-
rian cysts and the uterus, accidental wounds
of the abdomen followed by protrusion of
the intestines, and even the severer forms
of abdominal injury in which the spleen
has been removed, have all occasionally
been unattended by alarming signs of in-
flammation. The results of experiments,
by the same author, on the abdominal cavity
of the lower class of animals, tending to
show the extent of injury which they will
suffer with impunity, bear with much less
force upon the question; for, though ana-
logy may be highly instructive in illus-
trating the processes of nature, the power
Researches, Phy. and Path. By James Blundell,
M. D. 1824.

HOW FAR DANGEROUS.
9
of bearing injuries, and the disposition to
inflammation, as their consequence in the
human subject, cannot, by the utmost stretch
of analogical reasoning, be inferred from
experiments made on the brute.
Analogy, however it may serve to show
that wounds of the abdominal cavity are
by no means so dangerous as may be com-
monly supposed, at best affords but pre-
sumptive evidence that the operation, under
favourable circumstances, would in many
cases be successful. But, as I have men-
tioned, the want of control over the cir-
cumstances under which the surgeon is
compelled to perform the operation, will
throw into his hands many cases which
neutralise the calculations of theory and
experiment.
Mr. Hey, who is regarded as a successful
operator for hernia, observes, that when he
performed the operation late, he only saved
two patients out of five; and when he
performed the operation early in the dis-
ease, he lost two in nine. In this calcu-
lation, he says that he does not include the
cases which he has lost from mortification

10
AVERAGE SUCCESS CH
of the bowel. This gives an average of
five unsuccessful cases out of fourteen, ex-
clusive of the cases of gangrene, or a loss
of more than one third; and supposing
one or two cases of gangrene in addition
to the five unsuccessful cases, we should
have six or seven fatal cases out of fifteen
operations. In looking over the five first
volumes of the Lancet hospital reports, I
find six cases detailed, out of which five
proved fatal.
In order to show how far this operation
is applicable to the majority of the cases
of hernia that come under a surgeon's no-
tice, I subjoin a brief description of thir-
teen fatal cases that have occurred in Guy's
Hospital within the last few years. As
the condition of the intestine, omentum,
and of the sac, was in each case ascer-
tained, any objections to the practicability
of performing the operation without open-
ing the sac, as far as the contents were
concerned, must have appeared. The cases
are not selected, but taken in succession
from the report books of the Hospital, or
199, doidy coas
* Hey's Surgery, p. 129.
7505
#3072

OF THE OPERATION.
11
from the private book of my late dresser,
Mr. Nunneley, who kept notes of all the
cases of hernia occurring in his time.
The majority of the cases appeared to
have died from peritoneal inflammation
consequent upon the exposure of an in-
flamed or strangulated portion of bowel.
I say, exposure of the bowel; for it is, pro-
bably, not so much the wound in the
peritoneal sac that disposes to inflamma-
tion, as placing the bowel under circum-
stances to which it has hitherto been
unaccustomed. The sudden change of
temperature to which it is submitted, the
exposure to light, and to a current of air,
cannot but have some influence upon the
delicate circulation of the part, and be pro-
ductive of some impression on the nerves
of so susceptible a surface as that of a
strangulated intestine; and if to these in-
fluences be added the handling which the
gut usually experiences, the re-action that
follows these agents we must regard as a
natural consequence, and likely (as expe-
rience proves) to amount to excessive in-
flammation. In tracing the inflammation

12
CASES.
consequent upon an operation for hernia,
it is found to spread from that portion of
the bowel that has been strangulated, over
the peritoneal surface of the intestines,
and not to have its origin from the incision
in the sac, although two wounds are usu-
ally inflicted upon it; one for the purpose
of exposing its contents, and another higher
up to divide the stricture: the peritoneum
about the seat of stricture exhibits fewer
signs of acute inflammation than the in-
vestment of the bowels. dific
CASE I.
A man aged thirty-four, admitted for
some venereal affection, was seized with
sudden indisposition on the Monday, which
increased on the Thursday to well-marked
symptoms of ileus. The matter vomited
became stercoraceous, and the constipation
could not be overcome by the remedies
prescribed; he died on the seventh day
from the attack, without mentioning the
existence of a hernia to the apothecary
under whose treatment he was.
On exa-

CASES.
13
mination, a knuckle of the ileum, three
inches in length, was found in an inguinal
hernial sac, of a dark livid colour, and
appeared to have contracted some few
recent adhesions; and notwithstanding the
small size of the mouth of the sac, and the
sharp edge of the ring, the intestine was
readily withdrawn into the abdomen with-
out dividing the stricture. A large piece
of omentum was contained in the sac, bound
down by old adhesions. A part of the
omentum in the sac, and above its mouth,
was of a dark colour, but not in a state of
sphacelus: a quantity of dusky sanguisolent
serum had been effused into the abdomen;
the intestines were distended with gas, and
in many parts highly vascular.mendeng
CASE II.
A female was brought in with symptoms
of strangulation of several days' duration,
and so depressed as to lead to the suspicion
that gangrene, if it had not already taken
place, was about to supervene. The sac
and the intestine were therefore opened,

14
CASES.
and the intestine allowed to remain in the
sac after the division of the stricture. She
died before the end of the second day. The
intestine was of a dark dusky olive colour,
but free from adhesions; the intestine
above the stricture highly vascular, and
dilated. Effusion of plastic lymph was
found on the peritoneal surface of the in-
testines.
to dec
CASE III.
A stout middle-aged man, admitted for
a strangulated inguinal hernia of short
duration, but rendered so tender by the
patient's own attempt to reduce it, that
farther employment of the taxis was deemed
inexpedient. An incision was made upon
the sac, and a portion of intestine exposed.
Some difficulty occurred in returning it,
and in the attempt, some additional por-
tions descended: the convolution that was
found in the sac was thickened, and not re-
turned by the operator, who thought that
it was ulcerated internally. Inflammation
came on, and he sunk in two days. The

CASES.
15
CASE IV.
intestine in the sac was found in some parts
thickened, and of a dark colour. In the
report it does not appear that the intestine
was gangrenous, nor that there was any
ulceration found in the mucous mem-
brane: general peritonitis existed with
puriform non-plastic effusion.fromm A
simed latore ogaal bue bio n
bio me die hettim
abyleabbur
dein eds no
aid oncled od zie trods bebrses
A woman, aged about fifty, was admitted
for an old but small femoral hernia, that
had been only a short time strangulated.
The taxis with other measures failed, and
the operation was promptly performed
without any untoward circumstance. The
intestine found in the sac was in a healthy
and favourable state, and readily return-
ed after the division of the stricture. The
omentum was strongly adherent to the
mouth of the sac, and could not be returned
into the abdomen.
simono ne
She died under symptoms of inflamma-
tion in two days. The portion of ileum
that had been strangulated was found at
some distance from the sac, and appeared

16
CASES.
perfectly healthy. The peritoneum exhi-
bited a general state of congestion, with effu-
sion of a discoloured purulent serum. ogor
21
CASE V.
A muscular man, aged twenty-nine, ad-
mitted with an old and large scrotal hernia
on the right side, which had suddenly de-
scended about six hours before his admis-
sion. The taxis and other measures having
been tried, and failing to reduce it, the
operation was performed twenty-two hours
after the descent: a quantity of dark brown
fluid escaped from the sac; and between
two and three feet of small intestine, with
the dark colour of ordinary strangulation,
and a piece of omentum, were found in the
sac. The stricture being freely divided,
several long continued and fruitless at-
tempts were made to replace the bowel:
an opening was made into it to relieve the
distension, and the operator was compelled
to leave that portion in the sac.
The pa-
tient survived the operation about fifty
hours. The portion of intestine left in the

CASES.
17
sac appeared, on a post mortem examin-
ation, to be in a gangrenous condition, and
the peritoneal tunic of the intestines slightly
injected; a small quantity of ill-conditioned
pus was found in the lower part of the
sac.
CASE VI.
A man, aged sixty, admitted with a large
inguinal hernia, of forty-four years stand-
ing, strangulate; had been ten times at-
tacked with strangulation, but he could
always succeed in reducing it without much
trouble. The tobacco glyster and the taxis
had been tried; the latter with some degree
of force, which gave him much pain. After
his admission the warm bath was used, and
after it ice was applied for two hours and a
half, at which time the taxis was repeated
and with success, leaving a piece of irre-
ducible omentum in the sac. The bowels
were relieved, but he had symptoms of
peritonitis come on the third day after the
hernia was reduced, and he died on the
fifth day. On examination twenty-two
C

18
CASES.
hours after death, six inches of ileum were
found of a black colour, allowing the mu-
cous and serous membrane to be peeled
off; no mark of the stricture could be dis-
covered, and the gangrenous condition of
the bowels was considered to be attributable
to the force employed in the taxis. The
peritoneal surface was generally inflamed,
and covered with an effusion of puriform
serum. berlabu
CASE VII.ignore
Dingo ed and comely
A man, aged fifty-five, admitted with an
inguinal hernia of twenty-five years stand-
ing, strangulated for sixteen hours prior to
his coming to the hospital. He had been
bled freely, and the taxis ineffectually tried.
His pulse was compressible and natural; he
complained of great pain in the abdomen,
but could bear the hernia being handled.
The operator endeavoured, having divided
the external ring, to return the contents of
the sac, but could not succeed; and then
made an opening in the sac to the extent
of two inches; a piece of small intestine,

CASES.
19
very little changed in colour or texture,
was laid bare, but on account of the dis-
tended state of the abdomen it could not
be returned, and was, therefore, left in the
sac. He had abundance of feculent mo-
tions, after the exhibition of enemata and
purgative medicine. He died, however,
on the second day after the operation. The
intestine in the sac appeared to be inflamed,
and to have contracted recent adhesions;
the mucous membrane injected with blood,
and the mesentery ecchymosed. There
were no marks of general abdominal in-
flammation. A small hydrocele at the
lower part of the tumour was opened du-
ring the operation, and a portion of the
tunica vaginalis was in a gangrenous state.
واودا
CASE VIII.
Jasmina
A stout female, aged fifty-eight, was ad-
mitted with an umbilical hernia of ten
years' standing, which she had contrived to
keep up by means of the bone of her stays,
with the exception of a small piece of
omentum about the size of a walnut.
On
c 2

20
CASES.
the previous morning a large descent took
place, attended with some symptoms of
strangulation. The symptoms appearing
to be relieved with the appearance of fe-
culent discharge from the bowels, the oper-
ation was not thought to be immediately
necessary; but the symptoms again return-
ing in a less equivocal form, the sac was
opened, and exposed a ball of omentum
that appeared to be healthy, enclosing a
piece of inflamed small intestine. On ac-
count of the adhesions, the omentum being
healthy was left in the sac, and the intestine
returned. Peritonitis came on, and she
died twenty-nine hours after the operation.
The portion of bowel strangulated was
found to be a piece of ileum, about a foot
from the cæcum, of a dark colour, and the
serous covering was easily peeled off. A
small quantity of sero-purulent fluid was
effused in the abdomen. There were ge-
neral old adhesions of the omentum to the
anterior abdominal parietes from the sto-
mach to the umbilicus.
mulasico

CASES.
21
CASE IX.
A man, aged fifty-four, with femoral,
inguinal, and umbilical hernia, was ad-
mitted for strangulation of a piece of in-
testine and omentum in the femoral sac.
It had been strangulated for two days:
bleeding and other measures were resorted
to without effect. The operation was
performed soon after his admission: a
knuckle of intestine was found enveloped
in the omentum, the latter slightly ad-
hering to the sides of the sac by recent
lymph, the former free from adhesion; the
intestine, though dark, retained its natural
glossy appearance, and was, therefore, re-
turned into the abdomen. The patient sunk
in forty-six hours after the operation. The
intestinal canal around the seat of stricture
was slightly inflamed. The strangulated por-
tion was marked at the point of stricture
by a gangrenous line; the remaining por-
tion was of a chocolate hue, and was slightly
glued to the mouth of the sac.smow E
bus zicidido diw naisiayda ed to step ons
c3

22
CASES.
CASE X.
A man, aged fifty, was admitted with a
strangulated congenital hernia, that had
descended the evening before his admission.
He was bled, and the taxis used without
success. The hernia was large and tense,
and painful only on pressure; the taxis
was again employed, and he was bled to
twenty ounces. The operation was per-
formed. The intestine in the sac was dark
and much congested, but elastic and po-
lished; there was a large piece of omen-
tum adherent; the stricture was freely
divided, and the intestine, which was marked
by the stricture, but uninjured in its coats,
was returned, the omentum being left in
the sac.
He died about thirteen hours
after the operation, without any fæcal
evacuation. The body was imperfectly
examined, and the report not satisfactory
as to the cause of death.
CASE XI.
A woman, aged thirty, admitted under
the care of the physician with phthisis, and

CASES.
23
with vomiting, constipation, and abdominal
tenderness, which were not ascertained to
arise from a hernial descent until the fol-
lowing day, and which she had laboured
under for three days prior to her admis-
sion. A femoral protrusion about the size
of an egg was returned by pressure; but
the symptoms continuing, the sac was
opened, and a small quantity of serous
fluid escaped. Neither intestine nor omen-
tum were found in the sac.
evening she gradually sunk.
On the same
A post mor-
tem examination discovered extensive tu-
berculation of the lungs, and abscess. A
portion of ileum was found above the
mouth of the sac, about three inches in
length, of a dark dusky colour, with a pouch-
like distension occasioned by a division of
the two inner coats of the intestine from
the pressure of the stricture. Much pres-
sure had been used in returning the bowel.
Sero-puriform effusion, and traces of great
vascularity on the intestinal canal, were
observed.
aingni hotelaende o div
c 4

24
CASES.
lagimobde ban
CASE XII.
imov diw
The
A female, sixty-five years of age, was
admitted with a strangulated femoral her-
nia of the right side. It had descended
about ten days previous to her admission,
and was treated as a case of ileus.
discolouration of the skin, which was red-
dened, the infiltrated condition of the cel-
lular membrane, the abdominal tenderness
and vomiting having ceased, the hiccough
having diminished, and the distended state
of the abdomen, together with the smallness
and intermission of the pulse, led to the
opinion that gangrene had taken place. The
sac was opened, and a coil of intestine was
discovered quite sphacelated, and in some
parts opened by ulceration, through which
an oozing of fæcal fluid was discovered.
The stricture was divided, and the intestine
opened. The patient lived until the fourth
day, and then sunk exhausted.
Gothing-on92
CASE XIII.
A man, aged fifty-five, was admitted
with a strangulated inguinal hernia, which

CASES.
25
had often descended through the ring,
and had been returned with some difficulty.
He wore his truss upon a small piece of
irreducible omentum. The shape of the
swelling was peculiar: the hernia, instead
of passing downward into the scrotum,
turned, after emerging from the inguinal
canal, over the tendon of the external ob-
lique muscle, and appeared somewhat like
a femoral hernia. The testicle had never
descended lower than the external ring,
and explained the peculiarity in the course
of the hernia. The symptoms of stran-
gulation were not severe, and the abdomen
was not very tender. An enema brought
away fæcal matter. The sac being laid
bare, was found between the superficial
fascia, and the external oblique tendon;
the stricture at the external ring was very
slight, and was divided; the contents of
the sac were found to be a large loop of
small intestine and a piece of omentum;
the former being healthy was returned;
the omentum, which was somewhat changed
in structure, but free, was left in the sac.
These symptoms were all relieved by the

26
THE OPERATION
operation; but inflammation came on, and
he died on the third evening after its per-
formance. General peritoneal inflamma-
tion, with sero-purulent effusion, was dis-
covered on a post mortem examination.
jugai
9nd 1970 inmo
In reading over the outline of these
cases, it is obvious that the attempt to
relieve the stricture without exposing the
contents of the sac, could not have been
attended with any untoward consequence
in any of the cases, with the exception of
the two cases of gangrene, Nos. II. and XII.;
and in these the symptoms denoting the
approach or existence of sphacelus, were
sufficiently marked to point out to the
operator the necessary mode of proceed-
ing. Some of the other cases, in all pro-
bability, would have been benefited, had
the sac been left entire. Cases III., V., and
VII., in which the intestine was left in the
sac, would not have been placed in a
less favourable condition for recovery,
had the sac been unopened and the stric-

GENERALLY APPLICABLE.
27
ture merely divided; and it is far from
improbable that the contents might, in
each of these cases, have been returned
by using the taxis gently upon the tumour
after the pressure of the stricture had been
removed: or, if such attempt to return
the intestine failed, the operator could but
have left it in the sac, as he was compelled
to do after having opened it. Four of the
cases sunk after the intestine was returned
in a healthy condition; three of them,
Nos. IV., VIII., and XIII., decidedly from
peritoneal inflammation with effusion; the
other, No. X., probably from the same
cause, although the inflammation that de-
stroyed him was not of so intense a nature
as in the others, on account of the large
bleedings to which he had been previously
submitted. It may be fairly presumed,
that if these herniæ had been returned
without opening the sac, the event would
have been different. In the other cases,
the fatal termination seems not to be
wholly independent of the taxis, except in
the first case, in which the hernia was not
known till the patient's death; but had it

28
THE OPERATION FIRST
been early discovered, the case was, in
every respect, one adapted to this mode of
operating. No. VI. exhibits the effects of a
mischievous perseverance in the taxis after
moderate efforts had failed; and, as I shall
endeavour to show, if a less hazardous
mode of operating were to be generally
adopted, it would supersede the injudicious
force so frequently and so often fatally
employed, in order to avoid the hazard of
an operation. The two cases, No. IX. and
XI., seem to have suffered from the pres-
sure of the stricture, and also from the
force of the pressure in the taxis; and as,
at the time of the operation in one case,
such effect was not very clearly marked,
inflammation set up subsequently to the
operation might have been an aiding cause
in producing the disorganisation. But I
reserve these and other similar points for
subsequent consideration.
Such facts, with the inferences which
they suggest, seem to call upon surgery
for some mode of relieving hernia under
strangulation, that shall not expose the
patient to the same risk of inflammation

PERFORMED BY M. PETIT.
29
as confessedly attends the present method
of operating. The plan of dividing the
stricture without including the sac, or ex-
posing its contents, seems to realise this
object; and I shall proceed to show, how
far it is practicable in the different species
of hernia, what its advantages appear to
be, and the force of the objections that
have been made to it.
ague sbodont
Smells
sini
bas
conie bo!
The first case in which this operation was
practised occurred to Petit, in the year
1718: it was a case of femoral hernia; and
Garengeot, in his "Operations of Surgery,"
bestows upon it the following brief notice:
"Last May, 1718, I saw a crural hernia of
a woman, the operation of which had been
made by M. Petit, without opening the bag.
He only made use of his cushion; and the
patient, though advanced in years, was well
cured in eighteen days." "* The mention
* Croissant Garengeot's Chirurg. Operations, trans-
lated London, 1723. p. 132.

30
HISTORICAL SKETCH
of this case by Garengeot has no reference
to the prevention of inflammation by leav-
ing the sac entire, but is intended to illus-
trate the superiority of Petit's cushion to
the tent commonly used by surgeons of his
day in effecting a complete cure of the her-
nia after the operation. Petit's observation,
"Il y a plus de trente ans que j'ai mis cette
méthode en pratique pour la première fois;
et elle m'a réussi,"* &c. implies that he had
had, since that period, further experience
of the operation, and it is to be inferred,
from his subsequent reply to the objections
brought against it, with success.
It is not,
however, mentioned what was the nature of
tne cases in which he so conducted the
operation; nor are the steps of the ope-
ration more precisely detailed than are con-
tained in his ninth section.
When speaking of the operation on large
herniæ ("que l'on fait aux grosses hernies"),
Petit seems to attach no importance to his
own suggestion of leaving the sac unopened,
* Tr. des Malad. Ch. p. 329.

OF THE OPERATION.
31
but confines his observations to the ne-
cessity of relieving the strangulation by di-
viding the stricture, and recommends the
intestine, if it has contracted old adhesions,
to be left in the sac; and, even should it
be non-adherent, he dissuades the surgeon
from returning a large mass of intestine
that has for a length of time remained in
the sac, on account of the risk of inflam-
mation likely to follow the replacement of
a mass to which the abdominal cavity has
been long unaccustomed. His observations
on the subject of large herniæ contrast
strongly with the practice pursued and re-
commended by modern surgeons; for all
our best writers are unanimous in direct-
ing them to leave the sac entire in cases of
large herniæ, and to content themselves
with dividing the stricture. And the pe-
rusal of Petit's cases, though it will impress
the modern surgeon with a high opinion of
his experience and strong sense, will, at
the same time, convince him that they are
precisely the cases to which his new ope-
ration would have been especially adapted,
and in which, in the present day, a surgeon

32
MONRO'S CASES.
of experience would, if possible, avoid
opening the sac and exposing the bowel.
Dr. Monro, in the year 1788, again
brought this subject before the profession,
in his large work on the Bursa Mucosæ* of
the human body. He appears to have en-
tertained a very unfavourable opinion of the
results of operations for hernia in his time,
and attributes their fatal termination to the
practice of opening the sac and exposing its
contents to the action of the air; an opinion
supported by the results of some experi-
ments he made on animals, in which he
found that exposure of the intestine and
handling it frequently destroyed life. At
the time Dr. Monro began to recommend
the practice of dividing the stricture with-
out including the neck of the sac, only
one of Petit's cases had been published
by Garengeot; Petit's posthumous works
appearing in 1774, and Monro's first oper-
ation having been performed in 1770. The
latter advocates the operation with much
zeal and some sound arguments, and has
bet
Svad Bluo:
4058* Work on the Bursa Mucosa, fol. p. 43. hrs

MONRO'S CASES.
33
given three cases in which the operation
was successfully performed, and a fourth
in which it was attempted; but the oper-
ator, being foiled in his object of preserving
the sac entire, was obliged to open it just
below the stricture, and introduce a di-
rector under the neck of the sac.
CASE I.
In 1770*, he was called, with Mr. Wood,
to a woman, thirty-five years of age, with
a femoral hernia with symptoms of stran-
gulation, which had continued three days.
Finding it impossible to reduce it, he pre-
vailed on Mr. Wood to cut the tendon
without opening the sac, and then to at-
tempt the reduction; which was executed
with the greatest ease.
CASE II.
In 1774, in a case of hernia congenita,
to which he was called by Mr. Clarkson,
he found the neck of the sac, as well as
the tendon of the oblique muscle, ex-
*Op. Cit. p. 48.
D

34
MONRO'S
tremely constricted." After cutting the
skin and tendon, we with much difficulty
divided the stricture at the neck of the
sac; and having reduced the bowels, we
stitched the teguments."
The description which Monro has given
of the last case has led to a misconception
as to the manner in which the operator
divided the stricture. One author, who
does not seem to entertain a favourable
opinion of Monro's operations, infers that
he attempted to divide the stricture with-
out including the sac, but that, being un-
able to accomplish his object, he was
obliged to divide the neck of the sac.
"Dr. Monro," he says, "mentions four
cases in which he attempted this oper-
ation: he was obliged to cut the neck of
the sac in two; and adhesions prevented
the return of some of the parts in the
third."* A little attention, however, to
Monro's description of the second oper-
ation, will convince the reader that the
expression, "we with much difficulty di-
vided the stricture at the neck of the sac,"
03
* Lawrence on Ruptures, p. 250.

CASES.
35
is evidently not intended to imply that the
neck of the sac itself was divided, but the
stricture at the neck of the sac. The ana-
tomy of hernia was so imperfectly under-
stood in Monro's day, that, knowing nothing
of the structure of the inner abdominal
opening, as since described by Sir Astley
Cooper, and of the disposition of the trans-
versalis tendon, he could describe the
stricture in no other way, than as
"the
stricture at the neck of the sac," to dis-
tinguish it from that at the external ab-
dominal ring; which, it appears from his
description, he divided without releasing
the intestine from pressure. The diffi-
culty which he experienced in dividing the
stricture at the upper opening, and which
is readily explained by the nature of the
hernia, also renders it highly improbable
that he should have included the neck of
the sac, as he would not have encountered
any difficulty in completing the operation
in this manner. In the fourth case, in
which he did not succeed in dividing the
stricture externally to the sac, he explicitly
states, that he "cut the neck of the sac."
D 2

36
MONRO'S
CASE III.
At the end of 1781, he was called by
Mr. Arnott to a gentleman above sixty
years of age, with a large hernia, to which
he had been long subject, in a state of
strangulation. He proposed the incision
of the tendon, which was very easily
executed; and, after that, all the bowels
were readily returned into the abdomen,
except a portion that seemed to grow
firmly to the inner side of the sac. All
the bad symptoms disappeared; and then
the incision, the sides of which were
supported by stitches, closed like a com-
mon wound of the teguments.
To doog
CASE IV.
In 1782, he was called by two surgeons
to a case of femoral hernia, which had
been strangulated more than two days, in a
woman thirty-five years of age. He di-
rected the tendon to be cut; but, still
finding some resistance from a straightness

CASES.
37
and thickening of the neck of the sac,
they made a small perforation in the peri-
toneum, above the stricture; and intro-
ducing a probe bent semicircularly at its
point, cut the neck of the sac upon it. A
small portion of the ileum, which was
strangulated, was easily reduced, and the
patient recovered.
gui
Monro's cases reflect credit upon him-
self, and upon those who were concerned
with him in the operation. Few surgeons,
with the knowledge possessed at that time,
could have divided the stricture of a con-
genital hernia, at the upper opening of the
canal, without opening the sac; and it is
not a matter of surprise that he should
have found" much difficulty" in accom-
plishing it. The third case, in which " ad-
hesion prevented the return of some of
the parts," is one that peculiarly calls for
the operation: it appears, from his short
account of it, to have been an irreducible
scrotal enterocele of long standing; and had
the operation been performed in the usual
manner, a portion of intestine, after being
exposed, must have been left in the sac,
D 3

38
MONRO'S
and the patient, in all probability, would
have fallen a sacrifice to inflammation.
In the fourth case, he had recourse to a
different mode of operating, which he re-
commends as preferable to the free division
of the sac as practised by Pott and other
surgeons, namely, the making a small open-
ing in the sac below the seat of stricture,
for the introduction of a grooved director,
and dividing the neck of the sac upon it;
though the sac is opened, the contents of
the hernia are thus not exposed, and the
risk of inflammation, according to Monro,
is diminished. This operation, which cer-
tainly possesses some advantages over the
free incision of the sac as commonly prac-
tised, is still attended, in some degree,
with the risk of inflammation, while it
is open to all the objections that have been
urged against returning the contents of a
hernia without examination of their con-
dition.
Although I must join with the author
whom I have quoted, in condemning the
injustice of Monro's criticism of Petit, I
cannot withhold the tribute of praise from

CASES.
39
1812
the former author, as well for the boldness
of his surgery as for the novelty of his
operation. For Petit, though he is entitled
to the merit of priority, had performed
the operation only in cases of inguinal
herniæ, in which the stricture seems to
have existed at the external ring, and the
operation was comparatively easy; but
Monro has extended the operation to all
descriptions of hernia, to small protru-
sions, in which the operator has to exer-
cise more skill, as well as large.* Surgery
* Petit's description" de la manière d'opérer les
hernies sans ouvrir le sact," shows that he had only per-
formed it in cases in which the stricture was formed at
the external ring. "When the surgeon has laid bare
the hernial sac, and removed the fat and membranes that
cover it as far as the ring, he takes a broad sound, curved at
the end and grooved in the middle, introduces it between
the ring and the sac, and passes the point of the bistoury in
the groove, in order to divide as much of the ring as lies
over the end of the sound; and if he thinks that he has
not cut sufficient to disengage the ring, he continues to
push the broad sound under the ring to divide all that
lies upon the sound. By these means the sac remains
entire, and the tension of the ring being taken off, the
parts enclosed in the hernia are somewhat released from
+ Traité du Mal. Chir. tom. ii. p. 329.
D 4

40
SIR A. COOPER'S
has done justice to Petit, and has retained
his operations, but has neglected those of
Monro, probably because they were more
difficult of execution; but, while we acknow-
ledge the merits and originality of the
French surgeon, it is unnecessary to detract
from the utility and excellence of the Bri-
tish surgeon's operations. The operation,
as performed by Monro, is more generally
useful, because it is more frequently called
into practice: his success is encouraging,
and is not unworthy of the imitation of
modern surgeons, who possess anatomical
advantages to which he was a stranger.
In 1803, Sir Astley Cooper performed
the operation of dividing the stricture,
without including the sac, in a case of large
inguinal hernia, in a man aged fifty-four
years, in which, the intestine not being re-
constriction (sont moins à la gêne), and the surgeon can
return them by gentle pressure." It is needless to ob-
serve, that an operation so conducted would relieve very
few herniæ from stricture, as, with few exceptions, the
stricture is formed at the inner ring. Monro, therefore,
cannot be said to have borrowed the operation, which he
performed in the case of congenital hernia, from Petit.

CASES.
41
leased as soon as the external ring was
divided, he carried the bistoury under the
edge of the transversalis, and divided a por-
tion of it: this gave immediate relief to the
strangulated bowel; and slight pressure upon
the tumour returned the larger portion of
its contents. He had not an untoward
symptom, and in a week could bear the
pressure of a laced truss to support the
tumour *, - a portion of intestine being ir-
reducible from old adhesions.
In 1807, a large umbilical hernia came
under his notice, that could not be reduced
by the ordinary means, and which he suc-
ceeded in returning by carrying the bis-
toury under the edge of the tendinous
umbilical aperture, and dividing it. "I
made a very small incision opposite to the
neck of the tumour, exposed the fascia
which covered it, passed my bistoury be-
tween the fascia and the sac, and divided
the former to the edge of the umbilical
ring; then putting my finger to the edge
of the linea alba, I passed my knife through
* On Hernia, part i. p. 63. 2d edit.

42
SIR A. COOPER.
the umbilical opening, behind the linea alba,
and made a small division of it upwards;
then withdrawing the knife, I pressed upon
the tumour, and it immediately returned."*
In another case of irreducible umbilical
hernia, he performed the operation in the
manner recommended by Monro, with the
view of preventing exposure of the contents
of the sac; namely, by making a small
opening in the sac, just below the seat of
stricture, and dividing the stricture with
the neck of the sac. "I made the incision
upon the orifice of the sac, opened it, and
passed in a probe-pointed bistoury, and
dilated the stricture upwards; then press-
ing the intestine, I discharged its contents
into the intestine within the abdomen, left
it in the sac, and brought the edges of the
wound together with very little exposure
of the protruded parts, and with relief to
all the symptoms of strangulation."†
M. Boyer briefly recommends the sac
not to be opened in large inguinal hernia,
but the stricture to be divided by passing a
*Op. Cit. part ii. p. 41.
+ Ibid. p. 43.

M. BOYER.
43
director under the aponeurotic opening,
and introducing the bistoury upon it; or,
if that be impracticable, to make a small
opening in the sac, just below its neck, and
to divide the stricture from within the sac.
He especially recommends the operation
to be performed in this manner, when a
hernia is irreducible from adhesions, or
from the enormous volume of its con-
tents.*
ged
A writer in the Edinburgh Journal for
1814, under the name of " Inquirer," has
advocated Dr. Monro's operation, and,
from notes taken from the Doctor's lectures,
states the advantages of not opening the
His account, though somewhat highly
coloured, is true. "The surgeon," he ob-
serves, " divides the integuments by a
wound several inches in length, and then
proceeds by an incision of similar magnitude
to lay open the sac. After the viscera, thus
unhallowedly exposed to the pernicious
stimulus of a medium unusual to them (viz.
the atmospheric air), have been felt, fin-
sac.
*
dgrodile bre
Boyer, Traité des Mal. Chir. vol. viii. p. 257.

44
OPERATION
gered, turned over, and examined secundum
artem, the next step is to divide the stric-
ture, which one might suppose to be the
first object in view. The protruded bowels
are at length reduced; but not until, in all
probability, they have been brought into
such contact with a number of irritating
substances, such as sponges applied to the
wound, the fingers of the surgeon, or, per-
haps, even the sleeves of his coat. After
all this, can it be wondered at, if abdo-
minal inflammation comes on so often and
kills the patient?
66
Surely any surgeon would, at all times,
be willing to reduce the hernia without an
operation if it is practicable, and will think
it perfectly safe to do so. When the
operation is had recourse to in due time,
what new reason makes a change of plan
necessary? Why will he open the sac
now, when he would most willingly have
reduced it but a few minutes before by
the means usually called taxis? Surely
there is a manifest inconsistency in such a
proceeding; and although a practitioner
may screen himself from censure under

ADVOCATED.
45
the broad canopy of general usage, I sus-
pect he will not be able, without sophistry,
to elude the unsatisfied enquiries of his
own conscience."
தி now
66
The writer's recommendation not to
defer the operation is a little overcharged.
Allowing the enema a reasonable time
to operate, let the efforts at reduction be
renewed; and should they still be unsuc-
cessful, it may fairly be pronounced that
the patient has no chance but from an
operation; and, therefore, every minute
that is allowed to pass in further tem-
porising and delay, carries away with it,
beyond recall, a chance from the unfor-
tunate sufferer. I think all the steps
above recommended might, by an active
practitioner, be put fairly in force in one
hour at the utmost. Should a trial so
energetically conducted fail, the operation
ought to be instantly resorted to; as farther
attempts at reduction, in the present posi-
tion of things, is too often productive of
much ensuing evil."
"The manifest advantage of this mode
is, that a most formidable and often fatal

46
OBJECTIONS
operation will be converted into a simple
incised wound of the abdominal parietes.
The risk of subsequent visceral inflam-
mation would be so comparatively small,
as scarcely to be the subject of reasonable
calculation. The only objections of which
I am aware, are the probability of the
strangulation being occasioned by a fræ-
num passing across the mouth of the sac,
or a quantity of fetid fluid being accu-
mulated in the bottom of it. As for the
latter, I think no harm can result from the
whole contents of the sac being replaced
in the abdomen, as the water would soon
be absorbed. As for the former case, the
cause of strangulation will be readily as-
certained as soon as the integuments are
divided; and should it appear to be some-
thing in the mouth of the sac itself, a small
opening may be made in the neck, just
sufficient to admit of the obstacle being
divided. But I believe the existence of
a frænum is not found more than once in
a hundred cases; and for such a rare oc-
currence to be pitted against the operation
here recommended, could prove no more

AND ADVANTAGES.
47
than that one mode of practice is not
universally applicable."
This writer leaves out of his calculation
the occurrence of gangrene, as he pre-
sumes the operation to be resorted to
early, when the return of the contents of
the hernia by the taxis would have relieved
the symptoms of strangulation.in 8
A prominent character of the operation,
and one that raises it above many of the
objections that have been brought against
it, is, that should the attempt to execute it
fail, either from want of dexterity on the
part of the operator, or from any peculiar
difficulty in the case, the operation can be
completed in the ordinary way, by laying
the sac open. A surgeon may possibly find
great and insuperable difficulty in dividing
the stricture externally to the sac; or, having
divided the stricture, he may be unable, by
the best directed efforts, to return the con-
tents of the hernial tumour: in such a case,
he has not brought himself into any di-
lemma by his unsuccessful attempt; the
operation may proceed, as if it had not been
made; and neither patient nor surgeon are

48
DIVISION OF THE
in a worse position than if the sac had been
opened in the first instance, without the at-
tempt to preserve it entire. It is no slight
recommendation of the operation, that its
failure involves the surgeon in no embar-
rassment, but leaves him at liberty to adopt
the old mode of operation.
But an intermediate line of proceeding
remains for his choice, between the division
of the stricture on the outside of the sac,
and the laying the latter open in the usual
way, so as to expose its contents; namely,
the operation, as recommended and prac-
tised by Monro in his fourth case, of
making an opening into the sac below the
stricture, introducing a director into the
opening, conveying it under the stricture,
and dividing the latter upon it. Such a
proceeding diminishes the danger of in-
flammation, by less freely exposing the sur-
face of the intestine; and in a simple case
of recent enterocele, strangulated, appears to
be free from objection. An unusual degree
of tightness in the stricture at the inner
ring, in inguinal hernia, rendering it im-
possible to divide the tendon without

201 NECK OF THE SAC.
49
wounding the neck of the sac, or a thicken-
ing of the neck of the sac in femoral hernia
might render this modification of the oper-
ation expedient, and, perhaps, these are the
only cases in which it can be considered to
be strictly necessary, or, indeed, to possess
any decided advantages. If the stricture
could not be relieved without passing the
bistoury within the neck of the sac, the oper-
ation would be preferable to the more free
incision of the sac; but it would not render
the return of the contents of the sac more
easy than if the stricture were divided on the
outside of the peritoneum. It also equally
conceals from examination the state of the
intestine and omentum, and precludes the
possibility of knowing whether they are in
a condition to be returned into the abdo-
men. To these latter objections it is equally
liable with the external division of the
stricture.
emit edd as boneco ed dos
The experience of Sir Astley Cooper in
its favour is accompanied by an allusion to
the advantages that attend it, and by the
expression of his conviction " that the oper-
ation will be gradually introduced into ge-
E

50
SIR A. COOPER'S OPINION
neral practice when it has been fairly tried;
and will be found, if performed early, to be
free from danger, and attended with no un-
usual difficulty."* In ordinary herniæ, he
says, that dividing the tendon without in-
cluding the sac avoids the danger of wound-
ing the bowel, which has occasionally hap-
pened when introducing the bistoury within
the sac, and in the event of the epigastric
artery being wounded, the hæmorrhage does
not take place into the abdominal cavity.†
In large herniæ he strongly dissuades
the surgeon from opening the sac, chiefly
on account of the handling to which the
intestines are necessarily subjected in re-
turning so large a mass into the abdomen;
and also from the difficulty of retaining
them in the abdominal cavity after they
have been replaced. In large irreducible
herniæ he recommends that the sac should
not be opened, as the time required for the
separation of extensive adhesions would ex-
pose the intestine to great risk of inflam-
mation.
* Part I. p. 64.
† Page 39.

OF ITS ADVANTAGES.
51
I need not again urge the main benefit
derived from the external division of the
stricture in the non-exposure of the patient
to those causes of inflammation, to which
the ordinary operation subjects him, and,
as experience frequently proves, with most
unhappy consequences. The exposure of
a bowel in a state of incipient or active
inflammation, the handling it in this sus-
ceptible state, the incision made into a pe-
ritoneal bag already disposed to, if not in
an actual state of, inflammation, are, as every
surgeon will admit, and as his forcible ef-
forts to reduce the hernia without the knife
prove that he feels them to be, dangers of
no ordinary magnitude to a patient labour-
ing under a strangulated intestine. I do
not feel that I have exaggerated the risk
of inflammation; for frequently enteritis
comes on, when at the time of the oper-
ation the bowel appears to be healthy, and
the abdomen free from tenderness; and
when general inflammation precedes the
operation, the release of the intestine by
the knife rarely succeeds in checking it.
Cases are sometimes met with in which
E 2

52
INFLAMMATION
the patient appears to be doing well after
the operation, the evacuations being free
and natural, and the sickness and pain sub-
siding; but after the lapse of two or three
days the powers begin to sink, the abdo-
men, though not very tense, is uneasy under
pressure, the pulse small and quick, and the
tongue becomes dry and coated. This con-
dition is, perhaps, protracted for several
days, and the patient at length dies. A
post-mortem inspection discovers the cause
of death in the dark colour and lacerable
condition of the strangulated portion of
bowel, and the vascular state of the sur-
rounding parts.m
This unexpected termination of a case,
when it does occur, usually takes place in
patients of enfeebled constitution, whose
powers are unequal to the restoration of
the healthy circulation in the strangulated
bowel after its release from the stricture;
and in whom, therefore, a slight degree
of inflammation gradually ends in the ex-
tinction of its vitality. At the period of
the operation the intestine, when exposed,
presents none of the usual indications of

PREVENTED.
53
present or approaching gangrene; no in-
filtration of its tissues, no discoloration
beyond that which retarded circulation in
a healthy bowel produces, no lack of pe-
ritoneal lustre, and no lacerability of
texture; it in no point appears to differ
from those cases of strangulation, in which
an early operation is had recourse to before
severe symptoms come on, and in which
a favourable prognosis is verified by a
rapid convalescence. Exposure of a por-
tion of bowel possessing such feeble powers
of resistance to morbid influence cannot
but tend to increase, probably to excite,
a disposition to inflammation; which,
though low in degree, is sufficient to de-
stroy its vitality; and it may, therefore,
be fairly regarded as the main agent in
the production of gangrene.
In cases in which great depression of
the powers are observed to precede the
operation, death sometimes rapidly takes
place without any other obvious cause
than the exposure of the bowel. The
condition of the patient is often found to
be manifestly worse after the operation,
E 3

54
EXPOSURE OF THE BOWEL
and stimulants are obliged to be plentifully
administered, in order to sustain the sinking
powers of life. This may happen without
inflammation of the abdominal cavity, or
gangrene of the bowel; and is attributable
solely to the depressing effect of the
operation. The pulse, which before the
operation was feeble, becomes fluttering,
and scarcely perceptible; the countenance,
which was anxious, now bespeaks the ap-
proach of death; the skin is covered with
a clammy moisture, and the whole frame
is seized with a restlessness that gradually
ends in the calmness of dissolution.
Mr. Wallis of Melsham, Norfolk, allows
me to mention a case that occurred in his
practice last year.
Mrs. C, aged forty-five, sent for him
in the year 1829, on account of a swelling
in the groin about the size of an egg,
attended with sickness and constipation
of the bowels; which, by means of the
warm bath and subsequent use of the taxis,
was partly returned. The remaining part
of the swelling gradually went away under
rigid abstinence. A truss was recom-

SOMETIMES QUICKLY FATAL.
55
mended, and for some time worn; but
being an active woman, she at length
discontinued its use. Occasional attacks
of sickness and pain, which she experi-
enced, were usually relieved by a little
rhubarb, with aperient injections. On the
16th of October, in last year, she was again
seized with the same symptoms, the tu-
mour being as large as when Mr. Wallis
first saw it in 1829. But in this attack
there was a greater degree of anxiety and
restlessness, with a surprising prostration
of strength. She was bled twice, and had
injections administered with the warm
bath. After some hours, the taxis ap-
peared to reduce the swelling to half its
size, and some part of its contents slipped
into the abdomen. The bowels became
soon relieved, but in other respects the
symptoms remained the same. Suspect-
ing, therefore, that a portion of the cy-
linder of the bowel remained strangulated,
he thought that no time should be lost
in having recourse to the operation. Mr.
Wallis having met with an accident, a
neighbouring surgeon of skill was sent for,
E 4

56
VIOLENT TAXIS
and the operation performed. A knuckle
of intestine was found in the sac, dark-
coloured but healthy, and was returned into
the cavity of the abdomen. After being
put to bed, she became restless, throwing
herself about in bed, and her pulse scarcely
to be felt in about an hour after the
operation she died.
It is true that such a condition of bowel
is sometimes discovered on inspection,
post mortem, of a patient whose hernia has
been returned by the persevering taxis of
the surgeon; and in whom, instead of the
expected relief, a series of symptoms ensue,
as succeeded to the return of the pro-
lapsed parts in the case No. XI. This,
however, is comparatively rare, and only
shows that the prolonged and forcible use
of the taxis may occasionally prove as
destructive as the operation; and that
rough handling of a tender bowel tends as
much to produce disorganisation, as its
exposure does to induce slow inflammatory
action sufficient to overcome its vital
power.
It is a common remark among surgeons,

AVOIDED.
57
that there is no circumstance conducing
more to the ill success of the operation
than the violent pressure to which patients
are subjected in the employment of the
taxis. The surgeon, anxious to avoid an
operation attended with so much uncer-
tainty as to its result, keeps up for a length
of time such a degree of pressure as he thinks
in prudence ought to be applied. The same
unsuccessful efforts are renewed by another
surgeon, who thinks to succeed by using
a greater degree of pressure. He is suc-
ceeded by a third; who, determined to
return the hernia at all hazard, keeps up
a degree of pressure nearly sufficient to
rupture the distended bowel. After their
several attempts, the surgeon has to per-
form the operation upon a bruised and
inflamed intestine, requiring but the ad-
ditional agency of the operation to induce
sphacelus. Were the operation for hernia
attended with less danger, such violent
attempts at reduction would not be made;
the operation would be earlier resorted to:
and I cannot but think that, among other
advantages, the operation I now propose

58
DANGER OF EXPOSING
would, if generally introduced, have the
effect of rendering such violence less fre-
quent. An operation is often regarded
as a forlorn hope, resorted to in the ex-
tremity of danger, when the injurious
effects of delay and violence combine to
preclude a chance of success.
The effect of exposing a contused part
is seen in a common bruise: if the
soft parts are severely contused, the skin
remaining entire, the inflammation that
follows subsides without injuring the tex-
ture of the part. But if a small wound
accompanies the injury, the inflammation
proves destructive in its effects; slough-
ing of the cellular membrane, with co-
pious suppuration, ensues, and the process
of healing is tedious. Between a common
contusion, and an intestine, or omentum,
bruised by the taxis, there is a close ana-
logy: a breach of texture, in the one case,
leads to the same effects as exposure in the
other. Inflammation is in both the result;
and the vitality of the parts being im-
paired, disorganisation in both cases fol-
lows as the consequence of inflammatory

A BRUISED INTESTINE.
59
action. If the contusion be not accom-
panied by a breach of the surface, no harm
is anticipated; and just so if the bruised
contents of a hernia are returned without
a wound of the peritoneal sac, and con-
sequent exposure, inflammation, if it does
come on, seldom proves severe, and still
more rarely fatal.
The following case strongly illustrates
the force of these observations. The hernia
had been strangulated four days, but was
fortunately returned by the taxis. From
the symptoms, it is probable that the
bowel was in a state of inflammation, with
its circulation reduced to the lowest state
compatible with life. Had the operation
been performed in the usual way, and the
congested and feeble portion of bowel and
inflamed omentum exposed and handled,
a fatal termination of the case might have
been anticipated. As it was, the patient's
life was placed, for more than a fortnight,
in considerable danger. The condition of
the bowel, as well as that of the omentum,
was most precarious, and nature seemed,
for a long time, unable to restore its natural

60
CASE.
healthy circulation.
I am indebted to Mr.
F. Fagg, the dresser, for the particulars of
the case.
CASE I.
Борош
Anne Florence, aged forty-six, admitted
into Guy's Hospital, January 6th, 1833, at
three P. M.; a married woman, and has had
five children. After her last confinement,
seven years ago, she noticed a swelling,
the size of a walnut, in her right groin.
This has, at different times, been a little
larger; but she has always been able to
return the greater part of the hernia, its
return being accompanied by a gurgling
noise. She has never worn a truss.
Four days ago, having had more than
usual exertion in washing, she found that
the swelling was about twice as large as
before, but did not attribute its increase to
sudden exertion. She was soon after-
wards seized with violent pain in her
bowels, hiccough, and vomiting. These
symptoms have continued up to the pre-
sent time, gradually becoming more trou-
any

CASE.
61
blesome. Bowels have not been open
during the last four days. At present
there is considerable anxiety of counte-
nance; abdomen tympanitic, and slightly
tender on pressure; hernial tumour tense
and somewhat tender; pulse 100, rather
sharp and jerking. The taxis had been
used before she came to the hospital; and
she has taken a great quantity of medicine,
but has not been bled.
Five P. M.
The intestine was returned,
at half past four. There is still a small
portion of omentum in the sac.
evoted as
abhazals Enema Ol. Ricini stat.
moit een bas
elo sugaod
Eight P. M. The injection remained up
some time, and was followed by two scanty
fluid dejections. She has had a little hic-
cough, but no sickness or vomiting; pulse
100, less sharp.
January 7th. Slept but little, being
troubled very much by flatulence; coun-
tenance much better; abdomen less tym-
panitic, and very slightly tender; has had
slight hiccough; tumour not at all tender;
bowels three times freely open; dejections

62
CASE.
fluid and bilious; tongue slightly furred;
pulse as before.
8th. Slept better, but is still troubled
with flatulence and hiccough; abdomen
soft and less tender, but still slightly tym-
panitic; pulse 112, small, and rather weak;
bowels relaxed; tongue coated by a white
fur.
Mist. Cretæ, iss, 4tis horis; Hydr. c. Cret., gr. iv.
Pulv. Dover, gr. v. h. s. Catap. Sinap. scrob. cord.
Wine, 13 daily.
9th. Slept badly; hiccough still con-
tinues in a slight degree; abdomen soft
and free from tenderness; pulse as before;
tongue cleaner; bowels still relaxed; de-
jections offensive.
Mist. Cretæ, Infus. Catechu, aa 3j. ter die.
Hydr. c. Cret., gr. iv.; Pulv. Dover, gr. v. h. s.
10th. Slept better, and had very little
hiccough; bowels less relaxed; dejections
still very offensive; pulse stronger; tongue
more furred.
P.
11th. Bowels are more relaxed again;
pulse weaker.
Hydr. c. Cret., gr. ij.; Conf. Opii, gr. viij., 4tis
horis.

CASE.
63
12th. Had a good night; bowels less
relaxed; dejections of a healthier cha-
racter; slight hiccough.
P.
13th. Slept well, and expresses herself
to be much better; bowels much more
composed; pulse stronger.
Rep. Pil. ter die.
evia
14th. Had a bad night from griping
pain in her bowels, and is feverish this
morning; bowels are more relaxed; de-
jections offensive; pulse 108, small and
weak; slight hiccough occasionally.
Rep. Pil. 4tis horis.
Enema Amyli. c. T. Opii, m xxx. stat.
15th. Had a better night, and has less
fever; bowels not so much relaxed; no
hiccough, but still a little flatulence; pulse
100, rather stronger; tongue moist and less
sto
furred.
P.
16th. Slept well; pulse small and
weak; bowels still relaxed; dejections of-
fensive.
P.
Brandy, 33 daily.

64
CASE.
17th. Complains of griping pain in
her bowels; but they are less relaxed;
pulse a little stronger; tongue dry.
Emp. Lyttæ abdom., et P.
18th. Had a bad night, being troubled
very much by pain in her bowels and
flatulence; dejections are still very offen-
sive; the countenance is rather anxious;
and there is slight tenderness of abdomen
on making considerable pressure; pulse
weak; tongue moist: the blister has not
risen.
Mist. Cretæ, iss; Infus. Catechu, iss.
Liq. Opii Sedat., m x. 4tis horis urgente diarrhoeâ.
Pulv. Opii, gr. i.; Calom., gr. ss., h. s.
Catap. Sinap. hypogastrio.
19th. Had a better night; much less
flatulence, and scarcely any pain; bowels
not so much relaxed; dejections less
offensive; tongue rather dry.
Rep. Pil. hâc nocte; Rep. Mist. 6tis horis.
Brandy 13 daily.
21st. Had more pain in her bowels last
night, and the flatulence is increased;
bowels more relaxed; dejections dark and

CASE.
65
offensive; tongue clean and moist; pulse
as before; no tenderness of abdomen.
Svians!!
P.
Poseb
23d. Passed a good night; has less
pain in her bowels, but is still troubled
by flatulence; bowels are less relaxed; de-
jections of a healthier character; tongue
rather dry; pulse 104, still weak.
Rep. Mist. bis die.
Hydr. c. Cret., gr. ij.; Opii, gr. ss.
Omni alt. nocte.
25th. Feels much better; has had no
return of pain; pulse stronger.
P.
28th. Continues improving; has had
no pain in her bowels, and very little
flatulence; tongue clean; bowels three
times open since yesterday; dejections of
a healthier character.
Rep. Mist. semel die; Rep. Pil. omni alt. nocte,
31st. She has had a return of pain in
her bowels, and flatulence; bowels re-
laxed, and dejections offensive; pulse 84,
and weak; tongue clean and moist.
Rep. Mist., 4tis horis, et Pil. 3 it
F

66
ACCIDENTS
February 2d. Complains still of a little
pain and flatulence; bowels less relaxed;
dejections still dark and offensive.
6th.
Rep. Mist. bis die, et Pil.
She feels much better; has had
very little pain in her bowels, and they are
less relaxed; dejections light-coloured.
Hydr. c. Cret. gr. iv.; Opii, gr. j. hâc nocte, et P.
9th. Continues to improve, and is gain-
ing strength; bowels not too much open;
dejections healthy.
11th.
males! P.
She had considerable pain in her
bowels last night, and vomited a little sour
fluid; also had slight hiccough. She is
quite free from these symptoms to-day.
Omitte Pil.; Rep. Mist.
26th. She is now quite recovered.
Some of those accidents that have oc-
casionally attended the division of the
stricture are, in a great measure, pre-
vented; or, at least, the risk very much
diminished: hæmorrhage is one of them;
if it were to take place when the sac is

AVOIDED.
67
not opened, the blood would not flow into
the abdominal cavity. The vessels, how-
ever, are much less exposed to danger; for
the director in both inguinal and femoral
hernia is so placed, that the knife is carried
before the vessels; and thus the epigastric
artery, and the obturator, when it crosses the
femoral sac, will be more likely to escape.
The cremaster branch of the epigastric,
which, in one case mentioned by Mr.
Lawrence, furnished a very copious bleed-
ing, is out of the reach of the knife when
the latter is passed on the outside of the
sac.
In a case of femoral hernia that lately
occurred at St. Thomas's hospital, a small
branch given off from the obturator artery
crossed the fore part of the neck of the
sac, and was cut through in dividing the
stricture; the obturator artery itself, which
arose from the epigastric, passing into the
pelvis, behind the neck of the tumour.
Owing to some peculiarity in the hernia,
the operator, without being aware of it,
found that he had divided the stricture
F 2

68
HÆMORRHAGE.
without opening the sac; and thus the
blood that escaped from the wounded vessel
diffused itself into the cellular texture of
the abdominal muscles, and not into the
cavity of the peritoneum.
The intestine also is placed beyond all
reach of danger from the knife. It is often
endangered, and sometimes wounded in
the operation. In the division of the stric-
ture, it sometimes prolapses before the edge
of the knife, and is wounded. This more
especially happens in the attempt to divide
Gimbernat's ligament in the operation for
femoral hernia: the ligament lies so deep,
that the operator cannot follow the knife,
which he is obliged to bury deep within
the sac.
Sir Astley Cooper mentions this
accident, and gives cases in which it oc-
curred. I have also seen Mr. Abernethy,
when I attended his lectures in 1817,
produce at lecture a portion of ileum that
had been wounded in the operation, and
followed by a discharge of fæces when the
knife was withdrawn.
In bringing the intestine more com-

BOWEL WOUNDED.
69
pletely into view, although the stricture may
have been divided, it sometimes happens,
that drawing the bowel down from under
the stricture is suddenly followed by a
gush of fæculent matter. This has been
found to arise from an ulcerative process
induced in the bowel by the pressure of
the edge of the constricting band. It is
more frequent in femoral than in the other
forms of hernia. Such an accident cannot
attend the division of the stricture on the
outside of the sac.
Small collections of pus at the mouth
of the sac, attended with intestinal irri-
tation and peritoneal inflammation, are
occasionally found, on inspection, after the
operation of opening the sac. The fol-
lowing case presented this appearance,
together with a change in the condition of
the mucous follicles of the intestine. I
will not aver that this will not happen
if the sac be left entire; but it is probable
that the latter mode of proceeding would
much diminish the chance of suppuration.
The intestine was much chilled before it
was returned: this frequent and fruitful
F 3

70
CASE.
source of subsequent reaction and inflam-
mation would be wholly avoided.
CASE.
George Wallis, aged forty-eight, a sailor,
admitted November 2d, 1832, at a quarter
to eleven P. M. He states that he has had
a small swelling in the left groin for four-
teen years since that time, it has occa-
sionally been increased, but was easily
reduced to its former size. He had worn
a truss till the last fortnight; during this
time his bowels have been costive. Last
night the hernia became larger, whilst
exerting himself (as he states, in larking).
He was immediately seized with cramps in
his stomach and vomiting, which have con-
tinued up to the present time; his bowels
had not been open for two days. The
symptoms on his admission were, nausea
and vomiting of undigested food without
fæculent odour; hiccough; pulse 120;
abdomen somewhat tense, tympanitic, and
tender; countenance anxious; hernial tu-
mour in the scrotum, the size of a large

CASE.
71
duck's egg, and excessively tender. He
had been bled three times during the
day, and the taxis had been used for some
time.
Calom., gr. iij.; Opii, gr. j., stat. Enema Ol. Ricini stat.
Lotion, with muriate of ammonia and nitre, to the
tumour.
November 3d, seven A. M. He has had
less vomiting; but the hiccough is very
troublesome. The operation was pro-
posed; but the patient would not give
his consent.
One P. M.
The
Countenance more anxious;
pulse 100, and feeble; abdomen tense;
tumour less tender. He consented to the
operation, which was performed.
superficial fascia was considerably thick-
ened. On opening the sac, a large quantity
of dark fluid escaped, and only omentum
appeared. On this being drawn upwards,
a knuckle of small intestine was exposed,
about an inch of which was of a dark
port-wine colour, thickened and iechy-
mosed. After the stricture, which was at
the internal ring, was divided, the intes-
tine was returned, the unsound portion
F 4

72
CASE.
being left in the inguinal canal.
The
omentum was adherent to the neck of the
sac, and the greater part of it was cut off.
Magn. Sulph., 3ij.; Magn. Carb., gr. xv. 3is horis.
Four P.M.
Countenance
much less
anxious; slight hiccough; pulse 112, rather
jerking; abdomen less tense.
Ten P. M. He has had slight vomiting,
and the hiccough continues. He has taken
three doses of the mixture; but the bowels
have not been opened; passes a good deal
of flatus; abdomen less tense, and free
from tenderness. eldest
eelug
Rep. Mist., post hor. j.; Enema Ol. Ricini cras mane.
4th, ten A. M. Slept pretty well. The
injection brought away a copious, seybalous,
dark stool. He has had slight vomiting;
hiccough continues; abdomen soft and
free from tenderness; pulse 120, small,
and rather weak.
drods
Cataplasm. Sinap. scrob. cord.; Rep. Mist. 4tis horis.
Nine P. M.
Hiccough continues; no
anxiety of countenance; cannot keep any
thing on his stomach. He has just had

CASE.
73
an injection, which was followed by a
copious, fluid, bilious dejection.
Calom., gr. iij.; Opii, gr. j., stat.; Enema Ol. Ri-
cini cras mane.
food br Roldiers
5th, nine A. M.
Slept four hours. The
injection produced the same effect as the
last; hiccough continues; stomach rejects
every thing; pulse 130, and weak; abdo-
men free from tenderness.
Calom., gr. iv. stat.; Mist. Effervesc. i.; Tinct. Hu-
muli, 3j. 4tis horis.12
Ten P. M.
Hiccough relieved; no vo-
miting; bowels four times open since the
morning; dejections fluid and bilious; com-
plains of headach. binh caonojob mego
6th, eleven A. M. Slept pretty well, but
was rather delirious; hiccough continues;
no return of vomiting; pulse 100, and
stronger; abdomen free from tenderness;
has passed a copious solid dejection.
Calom., gr. v. stat.; Rep. Mist. sine Tinct. Humuli.
Eight P. M. Hiccough more trouble-
some; bowels four times freely open since
the morning.
Calom., gr. j.; Camphor, gr. j.; Opii, gr. iss. stat.
Emp. Belladonnæ, scrob. cord. et P.
7th, eleven A. M. Slept but little, and

74
CASE.
was delirious; hiccough continues; coun-
tenance somewhat anxious; has passed
three copious fluid stools; pulse 120, com-
pressible; wound healthy.
Calom., gr.j.; Opii, gr. ss. 4tis horis. Mutton broth.
Eight P. M. Hiccough very troublesome;
bowels relaxed.
Opii, gr. ij. stat.; Julep. Ammoni. Magnes. et Tinct.
Opii, iij. viij. 4tis horis.
8th, ten A. M. Slept pretty well; has
had slight sickness during the night; hic-
cough less troublesome; countenance im-
proved; pulse 110; bowels three times
open; dejections fluid and bilious.
Tinct. Opii, m. xx. ex vino stat. Arrow-root and
Wine.
ba One P. M. Bowels continue relaxed;
omentum at the external ring sloughy.
Opii, gr. j. statim.
Nine P. M. Sickness continues; hic-
cough relieved; tongue moist.
Quinin. Sulph. gr. ij. Opii, gr. ss. 4tis horis. Thirty
drops of Tincture of Opium in a tablespoonful of
brandy, directly.
9th, eight A. M. Passed a tolerable night;

CASE.
75
vomited the first two pills, but kept the
last on his stomach; countenance rather
depressed; bowels twice open.
Opii, gr. j. stat.
One P. M.
He kept the pill on his
stomach, but vomited some wine which
was given him; hiccough less trouble-
some; abdomen rather tympanitic, but free
from tenderness; pulse 120, and weak;
wound healthy; omentum sloughing; in-
ternal ring closed.
Opii, gr. ss. 2is horis. Mutton Broth and Porter.
10th, eight A. M. Thinks himself better;
no return of sickness; very slight hic-
cough; pulse 110, and soft; appetite im-
proved; has passed a solid motion. Lame
Pergat.
11th, ten A. M. Had slight nausea this
morning; no vomiting; slight hiccough;
has had three fluid stools; tongue furred,
but moist; pulse 120.
Rep. Pil. A blister to be applied to the pit of the
stomach, and dressed with Opium ointment.
Eleven P. M. He is exceedingly rest-

76
INSPECTION.
less; pulse 130, very weak; bowels twice
open.
Morph. Acet., gr. j. stat. et rep. post 2 hor.
12th, eleven A. M. Countenance very
much depressed; pulse 140, very feeble;
no hiccough; has passed two fluid stools;
extremities cold.
ing.
13th. Died at half-past nine this morn-
ES
earg
inquola muisemo
sad
Sectio Cadaveris, twenty-four Hours after
Death.
On laying open the abdomen, the
omentum was found to be thickened and
drawn tightly towards the internal ring;
small intestines adherent to internal ring
and glued together, thus rendering a small
collection of pus at the internal ring cir-
cumscribed; the portion of the ileum which
had been strangulated dark-coloured, but
not spacelated; a great quantity of fluid
fæces escaped from the intestines when
they were opened; patches of glandulæ
aggregatæ ulcerated, with lymph thrown
out on them; the peritoneal coat separ-

ADVANTAGES OF THE OPERATION. 77
ated with great facility from the ileum;
duodenum not at all affected.
Among the advantages accruing from
the operation of dividing the stricture
without including the peritoneum, I do not
enumerate many circumstances that, in my
view, go to support the operation, but
which others may consider as objections to
it. There is no proposition in surgery but
admits of being viewed in contrary lights;
and the arguments that an advocate may
bring forward to support his view of the
question are oftentimes adduced by an op-
ponent as the strongest objections to its
truth. In the present instance I can only
say, that I have given an attentive consider-
ation to the subject, and trust that what I
urge may be regarded as the result of an
honest and deliberate conviction, rather
than the effect of a partial and hastily
adopted opinion. I shall refer the reader
to the statement of the objections to the
practice, for those points that are here
omitted.

78
OBJECTIONS
Petit has anticipated many of the objec-
tions that might be, and in some instances
were, brought against the operation; and
I shall present the reader with his very
sensible remarks on the subject, that he
may judge of their force, and how far he is
successful in combating them.
"In the first place *," he says, "it is ob-
jected that this operation is difficult; if it
be performed, as I have just described, with
the director that is peculiar to myself, there
is not a surgeon who could not perform it
with ease, however little dexterity he may
possess; but the difficulty of a thing is not
the question, when it is useful and practi-
cable. It is said, in the second place, that
fluids are found shut up in the sac, which
are returned into the cavity of the abdomen,
where they may produce mischief: but I will
ask those who make this objection, would
they not, if they had reduced the tumour
without an operation, have returned it with
the fluids which were contained in the sac?
It is a mistake to suppose that this fluid
*Op. Cit. p. 329.

STATED.
79
can produce any mischief; it is analogous
to that which moistens the interior of the
abdomen, and, doubtless, comes from the
same source.
"Another objection is, that, if the intes-
tine or omentum be in a state approach-
ing to gangrene, and being returned into
the abdomen suppurate or give way, the
fæcal matters, not having an outlet at the
ring, spread over the abdominal cavity, and
destroy the patient. This objection is not
founded upon the observations I have made
in my public lectures concerning this man-
ner of operating, but upon what has been
written by some authors who have quoted
me, and who, from not having quite under-
stood me, have attributed to me and made
me say things that never entered my head.
I may be permitted to describe my method,
and to explain myself more clearly on the
points which they have not understood, or
which I have not made sufficiently clear in
my public courses of lectures. Had I pre-
tended that the disengagement of the ring
without opening the sac was a general mode
of operating, my critics would have been

80
PETIT S
correct in some points; but those who have
done me the honour to assist at my oper-
ations know, if they have attended to my
practice, that I do not practise it in all
cases: on the contrary, I may say, that I
have not made it as general as it might be
rendered; and when I shall have explained
its utility, I am persuaded that many per-
sons will employ it, and apply it in a variety
of other cases in which I have not yet put
it in practice, but in which, if opportunity
offers, I shall employ it. My opinion, then,
is, that with the exception of gangrenous
herniæ, those in which the intestine is
loaded with scybala, and some of those in
which the intestine contains foreign bodies,
all others may be treated in this manner;
there are some even which ought not to be
treated in any other way.
"Let a person ask himself,what use is there
in opening the sac? I know of none, unless it
be to expose the intestine and the omentum,
to provide a remedy for any changes that
may have taken place in them, to disengage
the intestine from itself and from the omen-
tum in hernia where the intestine is loaded,

ANSWER TO OBJECTIONS.
81
and to be able to touch the intestine itself,
the better to return indurated fæcal matters,
and even foreign bodies, should there be
any. Now, these three cases are those of
which I make an exception; in all others,
which constitute by far the greater number,
why open the sac? There is nothing to in-
dicate the necessity of doing so; it is even
highly advantageous to avoid this operation,
because the parts are not exposed to the
air; the surgeon does not run the risk of
wounding them in opening the sac; and,
moreover, I shall elsewhere show, that, as
regards the consequences, it is more advan-
tageous that the sac should not have suf-
fered any solution of continuity. From all
this I draw this inference, that it is better
to disengage the ring on the outside of,
than within the sac."
The little consideration bestowed upon
this method of operating by surgeons in the
middle of the last century is explained by
their ignorance of its advantages, and yet
is surprising, considering the futile nature
of the objections made to it, all of which
G

82
SHARP.
had been exposed by Petit." Amongst
other improvements," says Sharp, "of
the operation for the bubonocele, it has
been recommended in recent hernia to re-
turn the viscera into the abdomen without
opening the sac, from a persuasion that the
patient would be less liable to a relapse.
But I do not find that the proposal has met
with a favourable reception; and indeed
the objections to this new method seem
unanswerable; for frequently there is a
fetid water in the sac, which may prove
pernicious when voided in the abdomen.
Frequently the intestine and omentum are
mortified, though the hernia be recent; and
if the diseased omentum is not removed,
nor an opening made for the issue of the
excrement, when the eschar drops from the
intestine, the event must, in all probability,
be mortal." It will be observed, that Sharp
has laid himself open to the same charge
that has been brought against Monro, of
omitting the principal advantage accruing
from Petit's operation, and has contented
himself with repeating objections that had
* Critical Enquiry, p. 45.

HEISTER.
83
been previously urged, and had been re-
futed by Petit himself.
he
Heister rests his objections to the oper-
ation on the following grounds: 1st, Because
the sacculus sometimes adheres to the sper-
matic vessels (in allusion to Petit's oper-
ation of returning the sac).
2d, Because
the prolapsed omentum or intestine is
sometimes suppurated, which can neither
be cured nor discovered while the sacculus
is entire. 3d, Because the sac sometimes
contains a large quantity of fetid and icho-
rous matter, which would be this way re-
turned into the abdomen, to the great injury
of the patient; and Cheselden observes, in
his Anatomy, that he has found above two
pounds of fetid matter in the sac of a rup-
ture of this kind, which, according to the
preceding method, would have been, doubt-
less, returned into the abdomen. 4th, The
intestines or omentum sometimes adhere
to the external parts, from which they can-
not be separated without opening the sac.
5th, The sac being left entire may easily
occasion a return of the disorder. 6th, and
lastly, This method cannot succeed in those
G 2

84
RICHTER'S.
inguinal ruptures when the peritoneum is
lacerated. Heister goes on to observe,
that "Le Dran also disapproves of this
method, because he does not find it to be
attended with any particular advantage, and
because, in incarcerated rupture of some
days' continuance, the intestine may be
sphacelated, and ignorantly returned in that
state, by which means the chyle and fæces
would run into the abdomen, and possibly
kill the patient. He therefore concludes,
that the sac should always be opened when
the rupture is incarcerated."
""*
SOT
Richter, in his "Traité des Hernies,"
thus puts the question of opening the sac
or leaving it entire. "This method (speak-
ing of Petit's) possesses no utility, no ad-
vantage that can render it preferable to the
ordinary method. It is founded only on
the imaginary danger of opening the her-
nial sac. It is really indicated, when the
intestines adhere to each other, and to the
hernial sac, because the operator can hardly
open the sac without wounding the ad-
herent intestine. But in this case, where
* Heister's Surgery, p. 51.

OPINION.
85
it would be advantageous, it is not prac-
ticable, because the hernia cannot be re-
duced without first opening the sac, and
destroying the unnatural adhesions.
"2d, The performance of the operation is
difficult, sometimes even impossible. The
distended state of the sac prevents the sur-
geon passing his finger and director up to
the ring. This difficulty is especially great,
when the hernia is small, round, and situ-
ated just before the ring, and when the
patient is stout; it is not so difficult if the
patient is thin, if the hernia is scrotal, be-
cause the upper part is usually less volumi-
nous. I have myself proved this objection
to be well founded. I once tried, for my
own information, to cut the ring before
opening the sac, and could not succeed.
"3d, It is not easy to see any advantage to
be expected in this mode of operating. As
the hernial sac always remains in the scro-
tum after the operation, it is quite imma-
terial if it remains there after the sac is
opened or not. By adopting this method,
it may be affirmed that the patient has less
ban gosia G 3 joms noflregor

86
RICHTER'S
chance of a radical cure than by the or-
dinary method.
"4th, The contents of the sac are often
gangrenous, or highly inflamed, and ready
to fall into a state of gangrene; which can
only be ascertained after opening the sac.
When they are reduced without opening
the sac, the operator returns into the abdo-
minal cavity parts that are damaged, or
already gangrenous, and death is the result;
or, at least, one is never sure of the state
of the parts that form the hernia; con-
sequently there is a degree of uncertainty
attending the operation. Experience proves
that this has already occurred several times.
Mr. Achell returned a hernia without
opening the sac; the patient died after the
operation, and the intestines were found in
a gangrenous condition. Le Dran reports
a similar case. bom
"The parts contained in the hernia are
sometimes adherent to each other, and to
the sac. By opening the sac, these ad-
hesions can be destroyed, and the parts re-
turned. If the sac is not opened, this
separation cannot take place, and the re-

OPINION.
87
duction will be impossible. But supposing
that it is done, the parts that adhere may
be so twisted as to cause a fatal ileus.
This
is not to be apprehended in opening the
sac.
"There is sometimes in the sac a consi-
derable quantity of irritating fluid. Che-
selden found two pounds of a putrid sanies.
This fluid will be returned into the abdo-
minal cavity if the sac be not opened, and
it is to be feared that it might produce dan-
gerous consequences. By opening the sac
this sanies escapes, and the patient so far
escapes this danger.
66
Finally, this method is not at all prac-
ticable, when the cause of strangulation is
not in the ring, but depends on the neck
of the sac, or on some other part either
containing, or contained in the hernia;
because without opening the sac it is im-
possible to remove the strangulation and to
effect a reduction of the contents. Mr.
Bell has found the appendix vermiformis
of the cæcum firmly adhering around the
intestine contained in the hernia, and occa-
sioning strangulation. Mr. Callison has
G 4

88
RICHTER'S
seen the omentum contained in a hernia,
divided above into two portions, that united
below into a cartilaginous and hard mass,
and the intestine was strangulated in this
cleft in the omentum."
He proceeds to examine the other side
of the question, and to state some reasons
why the operation should be sometimes
performed.
"If it is objected," he observes, "that
in those cases that have not been long
strangulated, and when the danger of gan-
grene appears very distant, yet, without
suspecting it, gangrene may have com-
menced; and, therefore, one is never on
sure grounds in following this mode of
operating, even when the operation is per-
formed in time, and before the symptoms
are urgent, I make this answer: if the sur-
geon, after having decided upon the oper-
ation, makes one more attempt at reduction
by the tobacco smoke, or by the taxis, or
by any other means, and succeeds, the her-
nia is reduced without opening the sac, and
the parts contained in the tumour may be
damaged. Why should he not be afraid of

ENT OPINION.
89
doing that by the taxis, which only a
quarter of an hour afterwards he fears to
do in the operation? Will a surgeon of
sense be deterred by such reasons from
making the attempt? and ought not such
reasons, with equal justice, make him re-
ject the taxis, the tobacco smoke, and all
other means of reduction, because by all
such measures the hernia is reduced with-
out opening the sac?
"I therefore think that this mode of
operating is not to be rejected in all cases;
but, on the contrary, that it may some-
times be practised with utility and advan-
tage in certain specified cases."* beni
In regard to the difficulty of the oper-
ation, which I conceive to have been the
principal reason of it not coming into more
general practice, I apprehend that most sur-
geons will concur with Petit's opinion, that
the difficulty of executing an operation
ought not to have any weight in the scale
of objections, if it be found to be practicable,
and to possess decided advantages. The
* French translation of Richter, by Rougemont,
p. 120.

90
DIVISION OF THE
difficulty is much over-rated; and at the
present day, when anatomy is so thoroughly
cultivated, and especially that of hernia,
surely that which was effected by Monro
can be done by a surgeon who possesses
advantages to which Monro was a stranger.
I confess, however, that I was somewhat
startled by the difficulty of dividing the
stricture in this manner in inguinal her-
nia, until I had hit upon a method that
greatly facilitated the operation.
From the extent to which the stricture
is usually divided in order to return the
contents of the sac, it may, perhaps, be
imagined that a still more extensive divi-
sion is required, when the sac is not opened,
the surgeon consequently not having the
advantage of making such direct pressure
on the intestine and omentum, as he does
when they are exposed. The contrary,
however, I believe to be the case. If the
stricture is divided from within the sac,
parts are incised that have really no share
in constricting the hernia, as the sac itself
and the cellular membrane that intervenes
between the tendinous border forming the

STRICTURE.
91
stricture and the neck of the sac. If the knife
be applied to the tendinous band alone that
forms the stricture, a very slight division is
required; and I believe that in two of the
cases on which I have operated the extent
of the division did not much exceed the
breadth of the hernia knife; the passage
of the knife under the margin of the ten-
don was sufficient to remove the stricture,
and by very gentle pressure the contents
could be immediately returned. When the
tendinous band is divided, the parts sub-
jacent to it that surround the neck of the
sac, as well as the sac itself, dilate, when
pressure is made on the tumour, and offer
no resistance to the return of the contents.
I believe that in every case of strangulated
intestine a very little additional room is
sufficient to release the parts from pressure,
and to allow their escape into the abdomi-
nal cavity. Of this we have evidence in
the facility of returning the whole contents
of a hernia, when a very small portion of
omentum or intestine has been pressed into
the abdomen. of binh on wolle of one ed
The risk arising from the return of the

92
FLUID.2
fluid contents of the sac is an objection
that will hardly be maintained at the
present day, however seriously it may
have been put forth in Petit's time, when
the minds of surgeons were more impressed
with the humoral pathology. The fluid is
not the result of acute inflammatory action,
but of simple engorgement of vessels; the
blood enters the intestine or omentum
through the arteries, but cannot return by
the compressed veins; the serous parts of
the blood escape by the exhalent vessels
on the peritoneal surface, tinged with the
red particles. The absorbents of the peri-
toneum in all probability take it up, and its
presence in the abdominal cavity is not pro-
ductive of irritation. In every instance
where the taxis succeeds in returning a
hernia, the fluid, if any be effused, must be
returned with it; and the same objection,
as Petit justly observes, if it be worth any
thing, is equally valid against returning a
hernia by the taxis, as against dividing the
stricture without the precaution of opening
the sac to allow the fluid to escape.dsed
Adhesion of the intestine may possibly

RECENT ADHESIONS.
93
constitute a case that will not admit of it
being returned without opening the sac.
Soon after an intestine becomes incarcerated
and its circulation impeded, effusion of fluid
takes place, preventing the bowel coming
in contact with the parietes of the sac. If,
however, inflammation takes place in the
peritoneal covering of the bowel soon after
its descent, the effusion is of a plastic kind,
and adhesion ensues between the opposed
surfaces. The presence of fluid in the sac
will in most cases be sufficient to determine
the free condition of the bowel, or the slight
nature of the adhesion; while its absence,
especially if the tumour be hard and tender
to the touch, may lead to the suspicion
(not to the certainty) of adhesion having
taken place. When, under such circum-
stances, the sac is opened and the bowel
exposed, a very slight degree of force is
required to separate the adherent intestine.
It is true that this separation is not effected
by the pressure which the tumour undergoes
in the use of the taxis; but if the stricture
be divided, and the intestine be free to pass
into the abdomen, the adhesions, consist-

94
ADHESIONS.
ing of a thin pellicle of fibrine of perhaps
a few hours' formation, will probably give
way as soon as pressure is made upon the
tumour. This, however, is only opinion;
experience alone can decide it. But should
the intestine resist the attempt of the
surgeon to disengage it, he has then the
alternative of opening the sac and conclud-
ing the operation in the usual manner.
Much stress has of late been laid on the
importance of separating any recent adhe-
sions that may have formed between the
convolutions of the strangulated bowel, be-
fore returning it into the abdomen. This
practice is founded on the opinion, that
such adhesions, if left entire, impede the
peristaltic action of the bowel, and cause the
destruction of life. That adhesions, when
they bind down a portion of intestine at a
very acute angle, must check the progress
of its fæcal contents, is obvious; but such
cases are not common; and many of those
cases, in which death has been attributed
to a slight adhesion of a convolution, ap-
pear to my view to have sunk from the
effects of peritonitis consequent upon the

ADHESIONS.A
95
previous strangulation or incarceration, and
upon the operation combined.
It some-
times happens that a fold of intestine is
found in the sac, slightly adherent at its
points of contact; the adhesions are sepa-
rated by the operator, and the bowel re-
turned; the untoward symptoms continue,
and the operation fails in giving the patient
relief by evacuations per anum: if the
patient die, it is found that the bowels ex-
hibit the usual traces of acute peritonitis;
and the fold of returned intestine, which
may be distinguished by its colour, is seen
lying close to the neck of the sac, and its
peritoneal surfaces slightly glued together
by recent adhesive effusion. It is surely
unreasonable to attribute the peritoneal in-
flammation and the absence of stools to the
accidental slight adhesion of the returned
bowel; the adhesion is unquestionably the
effect of the inflammation and not the
cause, for the adhesion must have taken
place by means of an inflammatory process
established subsequently to the return of
the prolapsed bowel. Possibly, in such a
case, preserving the intestine from exposure

96
ADHESIONS AT THE
by keeping the sac entire might render the
termination of the case more favourable.
Much as I concur in many of the observ-
ations of the ingenious author* on inflamed
and obstructed herniæ, I cannot but think
that he has attributed more to the effects of
slight recent agglutination of the bowel
than experience will be found to justify,
and that he has regarded that as a cause of
the mischief, which ought rather to be as-
cribed to the effect of inflammation. idid
Adhesion of the bowel at the orifice of
the sac would, I believe, require the expo-
sure of the contents, in order to free them
from their attachment. Cases that are on
record show that there may be consider-
able risk in returning an intestine that has
been long adherent to the mouth of the
sac. The adhesions that remain drag the
intestine down, and confine it at so acute
an angle that a valvular impediment is
presented to the passage of the fæces.
Such an occurrence is uncommon; but a
fatal case occurred in St. Thomas's Hospital,
which is thus mentioned by Sir Astley
* Stephens. 1829.

MOUTH OF THE SAC.
97
Cooper:-"The sac having been opened,
the intestine was found very difficult to
reduce, from an adhesion between it and
the mouth of the hernial sac; but it was
at length apparently returned into the ca-
vity of the abdomen. Two stools were
procured by clysters on the following day
(27th of February), but from that time till
the 9th of March, on which day the patient
died, he had no stool. On examination of
the body, the ileum, which was the intes-
tine that had been strangulated, was found
in the mouth of the hernial sac, and doubled
back within it; the small intestine above
this portion was inflamed and greatly dis-
tended, and the jejunum was in a state of
mortification." Such a case as is here
described will not admit, with safety to
the patient, of the operation being per-
formed without opening the hernial sac.
From the difficulty which appears to have
attended the return of the bowel after it was
exposed and could be freely handled, it is
highly probable that its return would have
been nearly impossible while the sac re-
mained entire. In the cases in which I have
H

98
IRREDUCIBLE
divided the stricture externally to the sac,
the contents have been so readily returned
into the abdomen, that if any unusual diffi-
culty appeared to arise in returning them,
or if a portion of bowel should be imper-
fectly returned and should again descend
into the sac, I would recommend the opera-
tor to desist from any further attempt, and
to open the sac, in order to ascertain the
precise nature of the resistance. Cases of
this nature would not lead the surgeon into
any dilemma; for the difficulty he would
meet with in returning the intestine, would
induce him to resort to the usual mode of
operating.
In irreducible intestinal herniæ a differ-
ence of opinion may exist, whether it would
be advisable to remove the cause of obstruc-
tion without opening the sac. When symp-
toms of strangulation come on in irreduci-
ble hernia, they are found most commonly
to depend upon the mechanical obstruction
to the passage of the fæces, rather than to
any actual strangulation of the vessels of
the intestine; when the sac is opened and
the bowel exposed, it does not present the

HERNIE.
99
usual venous hue of extreme congestion,
but rather a florid colour, indicating an
increased activity of circulation, or the first
stage of inflammation. That any advan-
tage can attend the opening of the sac, and
the exposure of a bowel in this condition,
appears to me very questionable. What-
ever relief is to be afforded to the dis-
tressed bowel, can as well be given by di-
viding the stricture on the outside of the
sac, and thus enlarging the opening of
communication with the abdomen. I be-
lieve that this mode of freeing the bowel
from pressure, and the administration of a
dose of calomel and opium to tranquillise
for a time the action of the bowel, followed
in a few hours by a mild purgative, would
be sufficient to restore the function of the
intestine and to remove the symptoms of
obstruction. The opening of the sac, with
a view of removing the adhesions, is an
operation, to say the least, hazardous in its
consequences, when the division of the
adhesions can be effected, and oftentimes
useless, as the intestine in old herniæ some-
times adheres so extensively to the pa-
H 2

100
OMENTUM
rietes of the sac, that it is impossible to
detach them without endangering the
bowel; and the practice of returning the
intestine with portions of the adherent
sac, does not appear to possess any de-
cided advantage, as the cut surface of the
sac will, in all probability, contract fresh
adhesions to the parts with which it may
come in contact.
Where the adhesions are natural, as in the
instance of the cæcum forming the con-
tents of the sac, nothing more can be done
than to release the bowel by dividing the
stricture. I would recommend in such
cases the band to be more extensively
divided than in a common hernia, in order
to allow any indurated fæces to escape
into the colon. It is probable that in old
irreducible herniæ, the symptoms depend
more on obstruction of its contents, than
strangulation of its coats.
to woln
When my attention was first directed to
this subject, an adherent omentum seemed
to me likely to throw some difficulty in
the way of reducing a portion of intes-
tine, that might have descended into

ADHERING.
101
the sac and have become strangulated.
The difficulty of applying direct pres-
sure to a piece of intestine so circum-
stanced, and the possibility of it being
entangled by the omentum, appeared to
me rather to forbid the operation, and to
require the sac to be opened. But the
very first case in which I attempted to
perform it, was an old irreducible umbi-
lical hernia, in which a fold of intestine
had recently descended; and to my sur-
prise, instead of finding any difficulty in
returning it, the edge of the tendon being
divided, very slight pressure made on the
sac immediately caused the bowel to re-
turn. And I believe that, in many of
those cases in which the intestine is ap-
parently entangled by the omentum, a
slight division of the stricture would be
sufficient to release the bowel and induce
it to return; for although, when the sac
is opened from the outside, the omentum
may seem to entangle and to detain the
bowel in the sac, yet in reality the chan-
nel from the abdomen by which the in-
testine has descended may be quite direct,
H 3

102
COMENTUM ADHERING.
and the pressure of the omentum on the
intestine may be only apparent, and may
cease as soon as the tendon is divided.
The adhesion of the omentum to the neck
of the sac will not add to the difficulty of
dividing the stricture.
When the sac is opened, and its con-
tents exposed, the altered condition of
the omentum is sometimes such as to
render its return into the abdomen im-
proper; and the surgeon is recommended
to cut off the diseased or thickened por-
tion, rather than to leave it in the sac,
where it may prove a source of irritation.
That such a proceeding is impracticable,
when the sac is left entire, furnishes no
very valid argument against the operation;
the danger of irritation is less when the
sac remains unopened; nor is the patient
left in a worse state than when the hernia
is reduced by the taxis, and the thickened
and irreducible mass of omentum left in
the sac. It would hardly be thought ad-
visable to open the sac for the sole pur-
pose of removing a thickened piece of
omentum; they, who would recommend

GANGRENE.
103
such a step might, perhaps, think it better
not to wait till strangulation of the intes-
tine took place.
The condition of the bowel, that above
all others renders it an imperative duty to
open the sac, is that of gangrene. To
return a portion of mortified intestine with
the sac unopened, would expose the pa-
tient to almost inevitable destruction.
When, therefore, mortification is ascer-
tained to have taken place, or even sus-
pected, the surgeon has no alternative but
that of exposing the bowel, and giving
free room for the escape of the fæcal con-
tents.
It is a remark made by some surgeons
of experience, that the intestine is occa-
sionally found to be in a state of gangrene,
when no symptom had existed before
the operation to raise a suspicion of mor-
tification having taken place. It does not,
however, appear that any pains have been
hitherto taken to form a correct diagnosis
of the circumstances under which gan-
grene has actually taken place; nor am
I prepared to say that, in all cases, such
H 4

104
GANGRENE.
a certainty of diagnosis is attainable. I
think, however, that if the attention of
the profession were more closely directed
to the consideration of the condition pre-
ceding gangrene, a near approach might
be made, sufficiently accurate to direct a
surgeon's practice in all cases. In the
usual method of operating, it forms no
part of the surgeon's object correctly to
distinguish between ordinary strangulation
and a condition of sphacelus; it is suf-
ficient for him to determine the condition
of the bowel after the sac is opened, as
his line of proceeding in the operation,
until he exposes its contents, is the same
whether the intestine is in a healthy or in
a diseased state. When no evident ad-
vantage is to be derived from accurate
diagnosis, the attempt will rarely be made;
and hence the diagnosis of gangrenous
herniæ has hardly yet attained that pre-
cision which, I believe, closer observation
will not fail to bestow.
The ordinary characters of a completely
sphacelated portion of bowel are distinct
enough. The tumour loses its 'elasticity

GANGRENE.
105
and firmness; its surface becomes more
tender, or even inflamed; the skin is no
longer loose, but adheres more firmly to
the subjacent tunics of the hernia; infil-
tration of fluid in the cellular membrane
under the integuments sometimes takes
place, so that the part feels oedematous,
or sometimes emphysematous, and pits
on pressure. If an operation is not per-
formed, the integuments proceed to ulcer-
ation, or show here and there spots of
gangrene; a discharge of fæces at length
ensues, and gives the patient some relief.
This change in the tumour is too cha-
racteristic to be mistaken. But it some-
times happens that no such change takes
place in the swelling, and then the evi-
dence of gangrene is much more equivocal.
In the absence of any change in the state
of the tumour, the state of the abdomen
is generally considered as furnishing the
best evidence of the condition of the
strangulated bowel. It may be quite gan-
grenous, and yet the covering of the sac
may have undergone no change, in con-
sequence of effusion of fluid into the sac

106
GANGRENE.
at an early period of the strangulation.
Contact between the sac and the bowel is
thus prevented, and the former participates
less in the inflammation than when they
are adherent. The abdomen is frequently
free from pain or tension, even when the
bowel proves to be far advanced towards
sphacelus; indeed, the state of the intes-
tinal canal within the abdomen, affords
little or no criterion of the state of the
bowel in the sac. Sometimes, when the
abdomen is exquisitely tender, and shows
every sign of acute inflammation, the in-
testine is found to have undergone very
little change. The extent of abdominal
inflammation that is caused by a hernia,
will depend on the extent to which the
intestines are loaded at the time the de-
scent takes place. If the canal above the
strictured portion happen to be empty,
it will sustain little or no inconvenience,
especially as the patient is usually unable
to take food; and thus, for several days,
symptoms of inflammation do not make
their appearance. When the stricture upon
the bowel is so tight as rapidly to in-

GANGRENE.
107
duce gangrene, without producing general
inflammation of the abdomen, the sickness
is often very slight, but the patient's
powers are more depressed than under
ordinary strangulation; more anxiety of
countenance, more feebleness of pulse,
accompanied with a dampness of skin,
and also great indisposition in the patient
to have the tumour handled, are found to
attend this passive condition of the parts,
and afford strong suspicion of the approach
of actual existence of gangrene. To use
Mr. Pott's expressive language, "the coun-
tenance bespeaks death."
bad
In a case that occurred to me last spring
a foetid smell, similar to that described
by Sir A. Cooper, was perceptible in the
progress of the operation before the sac
was opened. An elderly female sent
to request the assistance of Mr. Burman,
surgeon of East Smithfield, for a violent
pain in the region of the stomach, which
she attributed to some indiscretion in diet
the preceding evening. A dose of calomel
with opium was prescribed, and on the fol-
lowing morning a draught of infus. sennæ.

108
DIAGNOSIS
Though her pain was removed, her bowels.
had not been relieved; and she then men-
tioned having the day preceding discovered
a swelling in the side, which she thought
had since disappeared. On examination
Mr. Burman discovered a femoral hernia
of considerable size, and finding that it
would not bear pressure, requested me to
visit the patient with him. We found her
with a feeble but not quick pulse, the ab-
domen free from pain, even when pressed,
but somewhat distended with flatus; she
had vomited only once; she thought she
had had her bowels open about two days
before our visit; but her account of the
appearance of the tumour was so vague,
and the state of her bowels so unsatisfac-
tory, that we could draw no inference from
the statement as to the length of time the
hernia had been down. It was very tender,
and her face and skin generally bedewed
with perspiration, with great anxiety of
countenance. The disproportion which the
state of the abdomen bore to the other
symptoms threw some doubt, in the event
of an operation, on the propriety of re-

OF GANGRENE.
109
turning the hernia without opening the sac.
Whatever doubt I might have entertained
was soon, however, converted into certainty
by the foetid smell that arose from the
swelling as soon as the fascia propria was
opened; it was a smell arising from a
decomposed portion of bowel and the
transudation of its fæcal contents. The
intestine proved to be quite gangrenous,
being black, devoid of lustre, and lacerable.
Such a foetor might, I apprehend, be dis-
covered in most cases of sphacelus, before
the sac is opened; its absence should be
ascertained in every case in which the
contents of a hernia are to be returned
without opening the sac. Before disor-
ganisation of the coats of the intestine
takes place, transudation of fluid or of
foetid air is probably prevented. In inci-
pient gangrene, therefore, it is not to be
expected.
Com
The length of time during which the
symptoms of strangulation have existed,
will, of itself, be insufficient to decide the
absence or presence of gangrene. Eight
and forty hours have, in some cases, been

110
PERIOD OF DESCENT
sufficient to disorganise the bowel; while
ten days will, sometimes, be found to have
produced no permanent change in its con-
dition. I have operated on an old woman
with a femoral hernia strangulated seven
days, and found the intestine in a condition
to be returned with safety into the abdo-
men. She recovered. In the following
singular case of incarcerated bowel, ten
days elapsed before its return, and, it is to
be presumed, without the occurrence of
gangrene.
In the year 1822, a man was sent into
the hospital by Mr. Robinson with a large
inguinal hernia in a state of strangulation,
which I could not reduce by the taxis
aided by other measures. Sir A. Cooper,
who saw him in the evening after surgical
lecture, proposed, as the symptoms were
becoming urgent, to perform the ope-
ration. The patient would not consent, and
left the hospital on the following morning.
He continued for several days in the most
extreme danger, his symptoms denoting
the accession of gangrene. His pulse in-
termittent, small, and varying from 70

NOT A CRITERION.
111
men.
to 96; perspiration profuse, countenance
most anxious, sickness distressing, and
great tenderness and tension of the abdo-
On the ninth day of the strangula-
tion, I was requested to see him, as he was
dying; the tumour had been diminished by
the ascent of a small portion of the bowel,
but his strength was so impaired that he
seemed unable to bear an operation. His
pulse was hardly perceptible, and he could
scarcely take nourishment. On the fol-
lowing day, the whole of the tumour was
returned, and from that time he began to
recover. Food remained on his stomach,
and with the exception of a severe diar-
rhoea that followed, he soon became con-
valescent.ab ino
It occasionally happens that the intestine
sloughs after it is replaced in the abdomen,
and the fæces pass for a time through the
wound. When at the time of the operation
the intestine has appeared healthy I have
known this to happen. A man from Wool-
wich, belonging to the artillery, was ad-
mitted into the hospital with strangulated
inguinal hernia of three days' standing. The

112
SLOUGHING
operation was performed by Sir A. Cooper;
and the intestine, though dark-coloured,
appearing to be merely congested, was re-
turned into the abdomen. In the evening of
the same day he passed stools per anum, and
appeared relieved. On the third day, as
soon as the poultice was removed, a quan-
tity of fæculent matter was seen issuing
from the opening. The discharge of fæces
continued for five days, at the end of which
time it altogether ceased, and the wound
speedily cicatrised. lod od: yeb galwol
A young man whom I visited with Mr.
Jackson, of Spitalfields, was the subject
of a strangulated congenital hernia, which
was so tender as to require the operation
to be performed without delay. The intes-
tine was very dark, but retained its lustre,
and was returned into the cavity of the
abdomen. On the fourth day, Mr. Jackson
found, on examining the part, that a copi-
ous discharge of fæces had taken place at
the wound. The abdomen had remained
tender since the operation, but he had
passes fæces per anum.
did not cease for several
The discharge
days, and de-

OF THE BOWEL.
113
layed the healing of the wound.
But
at the end of about sixteen days he be-
came convalescent, and the wound entirely
closed. boombong car low eat lo sin200
Such cases are not very uncommon; the
records of surgery furnish many; and the
practice of many surgeons may, possibly,
bring under their notice cases in which the
operation has been followed by a temporary
discharge of fæces. It is the consequence
of a small slough forming in the bowel: in
one case which I had an opportunity of
examining after death the slough was about
the size of a sixpence; the edges of the
aperture had contracted adhesion to the
neighbouring peritoneal surface, and the
breach in the bowel was filled up by the
serous membrane. The aspect of such
cases is at first unfavourable to the operation
of returning the intestine without opening
the sac and leaving an aperture for the
escape of the fæces. If the intestine slough,
and the fæces do not find an outlet at the
external wound, extravasation over the ab-
dominal cavity may be apprehended. To
what is the sloughing of the bowel to be
I

114
RISK OF GANGRENE
attributed? Not solely to the strangulation
that has preceded the operation, but to the
inflammation which the handling and ex-
posure of the bowel has produced. If in
such cases the bowel were to be returned
by the taxis at the moment the operation
was performed, in all probability the cir-
culation in the vessels of the bowel would
be restored, and the coats recover their
former healthy condition. The exposure
of the bowel to causes of inflammation in
its weakened condition leads to gangrene.
It appears to me that the operation of
leaving the sac entire is peculiarly appli-
cable to such cases; inflammation is pre-
vented, and the risk of gangrene much
diminished.
A remarkable case of this kind, that oc-
curred to Mr. Ramsden, is mentioned by
Mr. Lawrence. The strangulation had been
of two days' standing; and the bowel, which
was much discoloured, was returned without
difficulty. For six weeks she occasionally
exhibited symptoms of intestinal mischief,
which ended in a discharge of fæces at the
wound. Her appetite and strength failing

DIMINISHED.
115
her, she died on the eighth day after the
appearance of the fæces. A small ulcer-
ated aperture was discovered in a portion
of ileum, the coats of which were greatly
thickened, and its canal much contracted.
Even were gangrene to take place after
its return into the abdomen, it is by no
means certain that fæcal extravasation
would ensue. The peritoneal covering of
the bowel would adhere to the contiguous
surface, and thus its contents would be pre-
vented escaping. Nature would conduct
her operation of securing the abdomen
from extravasation when the eschar sepa-
rates, with more certainty, if there is no
wound in the peritoneum, than when undue.
inflammation is excited by opening the sac.
In a case of Dessault's, quoted by Mr. Law-
rence from the Parisian Surgical Journal,
it appears that a portion of intestine was
returned into the abdomen with an eschar
in its coats an inch in diameter. No sub-
sequent symptoms occurred to denote the
separation of the slough; and Dessault con-
ceives that the inflammation of the part
surrounding the eschar agglutinated it to
I 2

116
RISK OF GANGRENE
the parietes of the abdomen; and that the
slough passed along the intestinal canal.
The risk then attending the operation of
not opening the sac, as far as gangrene of
the intestine is concerned, appears to di-
minish, when the subject is fairly and fully
considered. I have noticed three states of
bowel that in this operation particularly
interest the surgeon, and in which there
seem to be at the first view insuperable
objections to returning the contents of the
hernia with the sac unopened. First, That
in which gangrene has actually supervened,
the signs denoting it being either an altered
condition of the coverings of the tumour,
a foetid exhalation before the sac is ex-
posed, or some unequivocal constitutional
symptoms. Such a state cannot lead the
surgeon astray from his obvious duty of
opening the sac. Secondly, That approach
of the bowel towards a state of sphacelus
which would induce a surgeon, if the bowel
were exposed, to place it at the neck of
the sac in the expectation of it falling into
a state of mortification. I will not advance
against the chance of gangrene coming on

DIMINISHED.
117
many cases that I have seen so treated,
and in which, contrary to the opinion of
the surgeon, the bowel soon regained its
healthy condition; for a stronger argu-
ment in its favour is to be found in the
risk of sphacelus being infinitely diminished
by the non-exposure of the bowel, and,
even should gangrene take place, in the
probability of a small eschar being cast
into the canal of the intestine without any
extravasation. Thirdly, The bowel being
found at the time of the operation in a
healthy state, and in a few days passing
into a state of sphacelus accompanied by
a discharge of fæces at the wound. This
occurrence the preserving the sac entire
is peculiarly calculated to prevent, by di-
minishing the chance of inflammation,
which in the weakened condition of the
bowel is the cause of the subsequent slough-
ing of its coats.
From the difficulty which occasionally
attends the return of a large mass of omen-
tum, it is not improbable that the sac of
an omental hernia will often require to be
opened, when the descended portion is
I 3

118
OMENTUM.
voluminous and the inguinal canal narrow.
Even when the abdominal rings do not
produce pressure sufficient to cause stran-
gulation, it is often very difficult to return
by the taxis a mass of incarcerated omen-
tum after a descent of only a few hours.
The return of an enterocele is readily
effected from the regular and smooth sur-
face of the intestine; but the lobular form
and irregularity of the omentum require
a more prolonged manipulation, and allow
of it being reduced as it were only piece-
meal: unless the rings are very wide, it
does not slip up at once, and not unfre-
quently requires some days before the
whole mass can be completely reduced.
Some years ago I experienced so much
difficulty in returning it after dividing the
stricture, that I was obliged to open the
sac. This case I have occasion to refer to
when describing the operation for inguinal
hernia. Should a portion of intestine have
descended behind the omentum, the former
might be returned, first, by making pres-
sure on the back part of the swelling, and
tnis would facilitate the return of the

NECK OF THE SAC.
119
omentum. After the stricture is divided,
the intestine would readily recede if pres-
sure be made directly upon it, and more
space would be afforded for the reduction
of the omental mass.
I will not omit the remote chance of the
neck of the hernial sac being thickened and
causing strangulation of the bowel: when
the stricture arises from this cause, the sac
must of necessity be opened before it can
be divided. A stricture from thickening
of the neck of the sac I believe to be a
very rare occurrence; and it is not impro-
bable, that in some of the cases in which
the stricture has been attributed to this
cause, the supposed thickening of the peri-
toneum arose from the band of fascia pro-
pria girting the neck of the sac. Before
the anatomy of femoral hernia was well
understood, the stricture was thought to be
produced either by Gimbernat's ligament,
or, if the stricture remained after that were
removed, by some alteration in the con-
dition of the peritoneal sac. There are
very few femoral hernia in which a firm
stricture will not be found to remain after
1 4

120
SYMPTOMS REMAINING.
Gimbernat's ligament has been divided or
even dissected away, produced by the ten-
dinous band at the mouth of the sheath
of the femoral vessels. Thickening of the
neck of the sac, therefore, may have been
thought to be a much more common oc-
currence than it is now known to be. It
may however happen; and when the stric-
ture is caused by it, the sac must be opened
to accomplish its division, as the contents
of the hernia cannot be otherwise returned.
In femoral hernia it is said to be more
common than in inguinal. In any kind of
hernia I believe it to be a rare occurrence.
A surgeon is sometimes embarrassed
by the symptoms of strangulation remain-
ing unmitigated after the tumour has dis-
appeared under the use of the taxis; and
when an operation is performed, or a post
mortem examination is instituted, the in-
testine is found to have been returned with
the stricture still girting it. Such a case
demands prompt and decisive measures:
the sac must be opened, and its orifice
explored, after means to reduce inflam-
mation have been fully tried, and have
failed to relieve the symptoms.

SAC RETURNED.
121
French surgery attaches more importance
than English to the risk of réduction en bloc.
The possibility of returning a hernial tu-
mour with its sac is fully established by
Le Dran and Scarpa. I have witnessed
an operation for crural hernia, in which
the operator attempted to return the tu-
mour, having mistaken the sac for the
intestine. Great force was used, and, at
length, the tumour disappeared; but the
symptoms of strangulation were not re-
lieved; and, on a post mortem examination,
the sac, with its contents, was found doubled
upon itself, and forced under the fascia
transversalis. I have never known this to
take place when the hernia has been re-
duced by the taxis. In the operation
which I propose, it is impossible to return
the hernia with its sac, and leave the
stricture upon the bowel. Great force
must be used to accomplish the reduction
under such circumstances; but the pressure
required to return the contents of the
tumour, after dividing the stricture on the
outside of the sac, is not more than is em-
ployed in reducing a hernia where strangu-

122
FORCE REQUIRED.
lation does not exist. I would not advise
more than this degree of pressure to be
used. If the surgeon find that a free
division of the stricture does not enable
the bowel to be readily returned, he should
relinquish the attempt. When the force
ordinarily employed in the taxis has failed
to return the hernia with its sac, no ap-
prehension need be entertained of this
accident occurring under a more moderate
degree of pressure.* Such a condition of
a hernia is hardly to be contemplated as
a possible occurrence.
Having given this brief historical notice
of the operation, and having stated the ar-
*For cases of this kind, I will refer the reader to
Lawrence's work on Hernia, pp. 142. 89. Cloquet's
"Recherches Anatomiques sur les Hernies." Mr. Law-
rence observes, "I have never seen a rupture reduced
in a mass in the way just described (alluding to M. Clo-
quet's description), nor have I met with any preparation
or specimen of such a reduction. Hence, as well as
from considering all the circumstances of the case, I
conclude it must be extremely rare. Its possibility
will hardly have any influence on our practical pro-
ceedings."

FIRST ATTEMPT.
123
guments that may be adduced in its favour,
as well as those that seem to be unfavour-
able to its success, I shall now detail my
own experience of it, and the steps of the
operation in the three most common forms
of the disease.
My mind had been very early impressed
with the advantages which leaving the sac
entire seemed to hold out; but, notwith-
standing it is so strongly recommended by
the best surgeons, during the whole period
of my attendance at the Borough Hospitals,
since the year 1812, the operation had
never been performed.
In 1829, a man, named Bessell, æt. 32,
was admitted into the hospital, June 28.,
with a large inguinal hernia in a state of
strangulation. He had been the subject of
hernia for five years, during which period
it had descended six or seven times. On
the day preceding his admission, it suddenly
came down, and, from the pain and sickness
it occasioned, he was obliged to be carried
home. He was bled largely, and the taxis
employed without success.
In consequence of the long trial of the

124
CASE.
taxis to which he had been subjected, the
tobacco infusion was thrown up before an-
other attempt was made; and, while he was
under the full effects of the narcotic, firm
pressure was steadily made upon the tu-
mour for a quarter of an hour, but with-
out diminishing the size of the swelling.
As the symptoms were urgent, and the
tenderness of the abdomen was consider-
able, I proceeded to perform the operation
without laying open the sac. Having laid
bare the external ring by a free incision in
the integuments, I passed a common direc-
tor under the edge of the ring, and divided
the tendon upon it until the edge of the
internal oblique and transversalis muscles
was exposed. The bistoury was then passed
upon the director under the cremaster, until
it reached the constricting band of the
transversalis tendon, which was divided to
a certain extent. Having, as I conceived,
divided the stricture, I endeavoured to re-
turn the contents of the tumour by making
moderate pressure upon it; but could not
succeed. Supposing, therefore, that the
stricture had not been sufficiently removed,

CASE. 227
125
The
I proceeded to divide a few more fibres on
the neck of the sac. In doing this, I made
a small opening in the peritoneum, and
therefore proceeded to open the sac in the
usual manner. The stricture had been
completely divided; and the impediment
to the return of the contents seemed to
arise from the very large portion of omen-
tum, which concealed a fold of small intes-
tine at the posterior part of the sac.
event fully justified my fears of opening
the sac, and the attempt to preserve it en-
tire; for inflammation of the peritoneum
soon prostrated his powers, and he only
lived thirty hours after the operation. The
surface of the intestines showed signs of
active inflammation, the peritoneum being
injected with blood, and covered with an
opaque serous effusion. The omentum,
which was ecchymosed in several points,
also presented signs of inflammation. dod
This being the first attempt to perform
such an operation, I was not surprised at
being foiled, as want of experience de-
prived me of that confidence in the oper-
ation which subsequent consideration and

126
FIRST ATTEMPT.
practice have produced. Were such a case
to occur again, I should be disposed to
persevere longer in the attempt to reduce
the contents, after I had fully satisfied my-
self that the stricture had been divided.
If the mass contained in the tumour could
be ascertained to be omentum, and the
symptoms at the same time gave reason to
suspect that a portion of intestine was also
included in the stricture, pressure should
be made on the posterior part of the sac,
in order to return the intestine first: this
would readily slip up after being released
from the pressure of the stricture, and
would enable the operator to return the
omentum with less difficulty. It may fur-
ther be remarked, that the operation was
not conducted in the manner in which I
now perform it, and I had not the assist-
ance of a properly constructed director, on
which much of the facility of the operation
depends.
This case, so far from discouraging me
in the operation, served to show its import-
ance, and that better conducted attempts
might still enable the operator to succeed.

FIRST ATTEMPT.
127
Within a few days after the above oper-
ation, a man was brought into the hospital
with a strangulated bubonocele, in conse-
quence of suddenly getting out of bed. He
was an elderly person, and had laboured
under asthma for two years. He had several
times noticed a protrusion at the external
ring, but, never having experienced any in-
convenience, had not paid much attention
to it. His symptoms, at the time of admis-
sion, were very urgent-complete consti-
pation, rejection of every thing that he
attempted to take, and constant distressing
attempts to vomit. Having employed all
the measures I thought advisable to adopt,
and kept up the taxis for a great length of
time, I reluctantly had recourse to the
operation. The man's unfavourable aspect,
which indicated visceral disease, and the
extreme tenderness of the belly, seemed to
promise but little chance of recovery, if the
abdomen were opened, and the bowel ex-
posed. I therefore endeavoured to lay bare
the transversalis tendon, and to divide it;
but not being able to discover it, I divided
such tendinous fibres as I could find girting

128
FIRST ATTEMPT.
the sac.
The stricture continuing firm as
before, and not having a flat director that
I could insinuate between the neck of
the sac and the very tight band of tendon
that was imbedded in it, I had no alterna-
tive but opening the sac. A dark small
knuckle of intestine was laid bare, and con-
fined by the tightest stricture I have ever
had to divide in any form of hernia. It
felt like a string tied round the gut, and
the director was with difficulty passed under
it. Its division was followed by a gush of
fluid, apparently the result of ascites. The
patient passed a good night after the oper-
ation, and had free evacuations from his
bowels; but in less than forty-six hours, he
sunk from the effects of abdominal inflam-
mation. The difficulty of dividing the
stricture was explained by the peculiar
nature of the hernia.
The protrusion was found to be of the
direct kind, the intestine having made.
its way through the external ring on the
inner side of the epigastric artery; and the
stricture was formed by a separation of the
fibres of the transversalis tendon, which

CASE.
129
surrounded and tightly girt the neck of
the sac.
Subsequent experience and observation
in my own practice, as well as the result
of cases of hernia in the practice of other
surgeons, having strengthened my impres-
sion in favour of leaving the sac entire,
I took the first opportunity of trying
the operation in a case of strangulated
umbilical hernia: the success attending
this case induced me to make trial of it in
one of femoral hernia that occurred in the
practice of Mr. Randall. The following is
the account given by Mr. R. before I saw
the patient.
CASE.
"Joseph Pavey, ætatis 44, a short, thick-
set man, of a sallow complexion, was, on
the morning of February 14th, 1832, sud-
denly seized with hæmatemesis.
In a few seconds he rejected from his
stomach nearly a quart of blood. He was
immediately taken to his own residence in
Abchurch Lane, when I was sent for, and
found him bleached and much exhausted,
Loft alogod

130
CASE OF
having a second time vomited blood of a
grumous character, and, I should say, full a
quart in quantity. I immediately ordered
him acidulated drinks, ices, &c., and gave
him large doses of nitric acid, which treat-
ment for a time seemed effectual in sus-
pending the discharge of blood. At about
9 P. M. he again vomited about a pint and
a half, and on the following morning, the
15th instant, a full quart was rejected, con-
sisting partly of fluids he had taken, but by
far the greater portion blood. A consider-
able quantity was also passed from the
bowels in connection with fæculent matter.
"Slight returns of vomiting took place
during this day, and on the morning of
the 16th he rejected a full quart, by far the
greater portion of which appeared blood.
"This last attack left him for some time
extremely exhausted, and for a short period
apparently lifeless. After an hour or two,
he began to revive. I then gave him a very
strong solution of sulphate of alum, in small
quantities, and frequently repeated. From
this time we had no discharge of blood from
the stomach, and what passed from the
bowels daily diminished in quantity, and

FEMORAL HERNIA.
131
on the 20th had quite disappeared, leaving
the evacuations of a healthy character.
"The patient went on well till the morn-
ing of the 1st of March, when his bowels
became a little irritable, and he had three
rather loose evacuations within a couple of
hours, the last about 8 A. M.; after which
he suffered considerable pain in the lower
part of the abdomen.
"I saw him about noon, and his report
was, that he had been remarkably well
till about 9 o'clock in the morning, when
he was suddenly seized with pain at the
bottom of his belly, which he considered to
have been greatly relieved by a little brandy
and warm applications.'
"I pressed the belly without removing
the bedclothes, and finding the bowels had
been free, and that there was no sickness
mentioned, and the belly by no means very
tender, I left him, advising him to take a
little medicine to allay the irritable state of
his bowels, to which he had referred his
pain.
"About 9 P. M. I was sent for in a hurry,
and found that the pain had increased, and
K 2

132
CASE OF
that he kept nothing on the stomach. I
immediately threw aside the clothes, and
was perfectly convinced that a small knuckle
of intestine had descended into the right
groin, and was strangulated.
"The man could not believe that his
sufferings proceeded from the small swelling
in his groin, for that had existed for years,
even when he was a boy at sea. Being
confident as to the nature of the malady, I
made such pressure on the tumour as the
man could bear, but could not return it.
Mr. Key, whom I consulted, recommended
the application of ice to the part through
the night, after the exhibition of calomel
and opium, and appointed to meet me at
8 the following morning."
In the morning I proceeded to visit the
patient with Mr. Randall, and found him
very ill, with a small jerking pulse, occasional
vomiting of a dark bilious matter, and the
abdomen very tense and tender. The tu-
mour in the groin was not large, but so ex-
tremely sensitive when pressed, that he
could not bear the taxis to be continued for
any length of time. The operation, there-
fore, became indispensable. In his weak

FEMORAL HERNIA.
133
condition, it was clear that a very slight
degree of peritoneal inflammation would
destroy him, and also, that a morbid con-
dition of liver, which was probably the cause
of the previous hæmatemesis, rendered him
predisposed to inflammation. I proposed,
therefore, to endeavour to return the con-
tents without opening the sac. The usual
incision having laid bare the fascia propria
of the tumour, I made a small opening in
it, sufficient to introduce a director up to
the seat of stricture under Poupart's liga-
ment. As soon as the director reached the
neck of the tumour, its progress was im-
peded; but, by pressing the point down-
wards, it readily passed under the stricture,
which was divided by a bistoury carried
along its groove. Passing the edge of the
knife under the stricture was sufficient to
release the bowel; very moderate pressure
being made on the swelling, the bowel
could be immediately felt to slip back into
the abdominal cavity: scarcely any blood
was lost during the operation.
The symptoms of strangulation subsided,
the wound quickly became cicatrised, and
9K 3

134
DIRECTOR.
in a short time, with the assistance of a
truss, he was enabled to follow his usual
occupation.
21
The inconvenient form of a common di-
rector induced me to have one constructed of
the shape represented in the first drawing.
The depth at which the stricture lies, and
the prominence of the tumour, render it
somewhat difficult to pass a straight instru-
ment betwixt Poupart's ligament and the
neck of the sac. The blade is below the
level of the handle, and is slightly curved;
the extremity being flattened, to enable it
to pass with more facility under a firm
stricture. The point of a common director
might lacerate the peritoneum, on account
of the pressure required to pass it under
the stricture. When I constructed this di-
rector I had not read Petit's account of the
one which he employed, which, from his
description, must resemble that which I use.
eds
bobiadura m
CASE.
Early on the morning of the 17th of
December, 1832, I was requested to see

CASE.
135
Mrs. I, ætat. 61, in consequence of a
femoral rupture that gave her some un-
easiness. She had consulted me about
two years since, for a femoral hernia on the
left side, which I had some difficulty in
reducing, and for which I enjoined her
to wear a truss. She now requested me to
see her, in consequence of the tumour
having again descended, and her not being
able to return it. When she was at the
water-closet in the morning, she was sud-
denly seized with pain in the lower part
of the abdomen; and, on placing her hand
to relieve the pain, she felt the tumour in
the groin. I made an attempt to return it
by keeping up pressure on it for twenty
minutes, but without success. Ice was then
applied till the evening, and the taxis re-
peated, with no better result. Some Dover's
powder was given her at bed-time, and in
the morning a castor oil enema was or-
dered. In the course of the night she had
vomited several times, and the abdomen
was becoming more tender. The castor
oil had not brought away any fæculent mat-
The circumstance of the hernia not
ter.
K 4

136
CASE OF
having descended during the last two years,
although she had neglected to wear a truss,
rendered it probable that the aperture was
very small, and that there was not much
chance of reducing it, especially as the tu-
mour was too tender to bear much pres-
sure; and, as she was too feeble to bear
the effect of tobacco or any considerable
bloodletting, I had recourse to the oper-
ation without further delay.
With the assistance of my dresser, Mr.
Langley, I exposed by means of a cru-
cial incision the fascia propria of the tu-
mour, and, making an opening into it so as
to expose the fatty investment of the sac,
I endeavoured to pass the director towards
the stricture; but, owing to the angle formed
by the tumour with Poupart's ligament, I
was obliged to divide the fascia more
freely towards the neck of the sac, in order
to reach the seat of stricture. The director
was then passed without difficulty between
the fatty covering of the sac and the outer
layer of the fascia propria, and carried
under the stricture. The blade of the bis-
toury was then passed along the groove, and
the stricture divided in a direction towards

FEMORAL HERNIA.
137
the umbilicus. The intestine was imme-
diately released from pressure; for, by ap-
plying a very moderate force to the tumour,
the intestine immediately slipped up; and
a small piece of omentum that remained,
was readily returned by a little farther
manipulation.
Her bowels were freely relieved after the
operation, without the aid of medicine; and
she continued to go on well, till the 22d,
with the exception of a slight tendency to
diarrhoea. On this day a blush of erysipelas
was perceptible about the wound, and the
discharge assumed an ichorous appearance.
Under the use of quinine, and a mild form
of opiate at bed time, she mended, and
by the 29th the wound began to form
healthy granulations. On the 8th of
January, a truss was applied, the wound
being nearly cicatrised.
The occurrence of erisypelas was evidence
of that disposition to inflammatory action,
which so often renders the operation for
hernia fatal. If the intestine had been ex-
posed, the inflammatory disposition would,
probably, have shown itself in the form of

138
CASE OF
peritonitis, and, in her feeble state, must
have at least placed her life in danger.
At three o'clock on the morning of Sun-
day, the 13th of January of this year, I was
requested, by Mr. Désormeaux, surgeon of
Pentonville, to see a lady whose hernia had
become strangulated. The account with
which Mr. D. has favoured me, is as fol-
lows:
"Mrs. T., about fifty years of age, sent
for me on Saturday, the 12th of January, on
account of a femoral hernia, which she
stated to have existed for several years, but
which she had been able to keep up with a
common truss. It had occasionally de-
scended, in consequence of the truss not
fitting her. In making some exertion, it
suddenly came down this afternoon, but
felt, as usual, when it happened to make its
appearance, soft and free from pain. In a
short time it became much harder and
painful, producing a great sense of tight-
ness across the belly, with nausea, which
soon ended in vomiting. I saw her in the
evening, and found her suffering great pain
with the hardest hernia I had ever felt.

FEMORAL HERNIA.
139
The tumour seemed to be filled with a mass
of hard indigested substances, which could
be felt through the skin, the coverings
being very thin. I attempted to reduce it
by the taxis, which was steadily kept up
for twenty minutes, and then she tried to
reduce it in her usual way, but without suc-
cess. It appeared to me impossible to re-
duce the tumour, without first kneading the
solid contents of the bowel through the
femoral ring, which, from the great solidity
of the matter, appeared to me almost hope-
less. I took from the arm as much blood
as brought on a fit of fainting, and then
made a second attempt to reduce it. Con-
ceiving that all measures would be useless
while the contents could not be moved, I
proposed having further advice."Arborella
When I saw Mrs. T. on the following
morning, I found, in the right groin, as
Mr. D. had described, one of the hardest
tumours I had ever felt, about the size of
a small orange, very tender, and the symp-
toms altogether urgent. She was in a
favourable state for the return of the
tumour, and I kept up considerable pres-

140
A CASE OF
sure, but could not make any impression
on it. In the extremely hard state of the
swelling, and the smallness of the neck
of the sac, which could be distinguished
in her spare person, I thought that no
advantage could be gained by delay, and
explained to her the little hope we en-
tertained of being able to reduce it. She
willingly acceded to the operation.hob
The integuments were so loose over the
tumour, that a transverse incision was suf-
ficient to expose the closer investments
of the sac; and the fascia propria being
exposed, an aperture was made into it,
and the director passed as high as the
stricture. The cellular membrane and
adipose structure were abundant, which
allowed the director to be passed readily
between the layers; but it was necessary
to depress the point very much, in order
to pass it under the stricture. As soon
as the knife was passed along the groove,
both Mr. Désormeaux and myself distinctly
heard the stricture yield; and at the in-
stant that pressure was made on the swell-
ing, the contents retired into the abdomen.

FEMORAL HERNIA.
141
The integuments were brought together
without suture.
wollo own ed: 20
Mr. D. gives me the following account
guived alled ods
of his patient :-
"Ten o'clock, A. M. 13th. The pain and
vomiting have ceased, but no stools have
passed. Pulse 110. The following draught
every three hours, till the bowels are re-
lieved: -et
Mag. Sulph. 3ij. Mag. Carb. 9j. Aq. Menth, 3j.
In the evening the bowels still remained
torpid, and she complained of tenderness in
the abdomen, but without sickness. Later in
the evening the bowels were freely moved.
Monday 14th. No pain; tongue clean;
pulse eighty-four; and she is doing well
in every respect. I
66
"Tuesday. She has passed a bad night,
and complains of much pain in the ab-
domen, and of a sense of tightness across
the lower part. Pulse 110. I ordered
the abdomen to be freely leeched, and the
draughts to be continued to evacuate her
bowels more completely. At night she
took a draught, containing 3 iss. Liq.

142
STEPS OF THE
Ammon. Acetat., with ten grs, of Pulv.
Ipecac. Comp.
"On the two following days she was
much improved in all respects; the pain
in the belly having ceased, and her pulse
being reduced in frequency. The wound
is healing by the first intention."
By the 18th she was pronounced to be
convalescent.
The extent, as well as the form of the
incision through the integuments, may
seem of minor importance, except as far
as it tends to facilitate the after steps of
the operation; yet it may be as well to
disturb the subjacent cellular membrane
as little as possible, as inflammation is
less likely to follow, and to assume the
form of erisypelas. For this reason, the
inverted T incision, usual in the operation
for femoral hernia, may be in most cases
reduced to a single incision, either at right
angles to Poupart's ligament, or in a trans-
verse direction across the tumour. In pa-
tients who are spare, and in whom the neck
of the sac lies at no great depth from the
surface, it is unnecessary to disturb the
Foot

OPERATION.
143
cellular membrane by turning aside the
flaps of the integument. This will diminish
the suppurative inflammation, and in such
cases will afford ample room for the ope-
ration. I have not made trial of the per-
pendicular form of incision, but a single
transverse one I have found sufficient, when
the integuments have been loose, and the
tumour not large. The superficial fascia
adheres firmly to the common integuments,
and is usually turned aside with them, es-
pecially when the latter are pinched up for
the purpose of making the first incision.
The fascia propria is, therefore, quickly
exposed, and forms the first distinct cover-
ing of the tumour, being darker than the
more superficial cellular investment. It is
under the outer layer of this fascia that the
adipose structure is formed, and which often
assumes the appearance of omentum. The
director easily makes its way under this
fatty matter as far as the neck of the sac,
which lies deeper than the operator at first
supposes. The point of the director should
be applied rather to the inner than to the
outer part of the neck of the sac, as it will

144
DIVISION OF
be found more easily to pass under the
stricture at this part. It should not at first
be attempted to be thrust under the stric-
ture, as the firmness of the parts forming
the stricture would resist it. But the seat
of stricture being felt, the operator should
depress the end of the director upon the
sac, which will yield before it, and then, by
an onward movement, the director slides
under the stricture. The usual seat of
stricture in a femoral hernia is too familiar
to need any elaborate description. The
appearance of the stricture, and its con-
nection with the fascia propria, are shown
in the Fourth Plate, fig. 3., of Sir A.
Cooper's work on Hernia, Part II. The sac
is removed, and the fascia propria, with
Poupart's ligament, is left entire.
tendinous band of the sheath, where it joins
with Poupart's ligament, is most accurately
delineated in Plate 2. fig. 3., and in Plate 3.
fig. 5. In these views Poupart's ligament,
has been removed, and the natural structure
of the sheath of the vessels which forms the
fascia propria of hernia is clearly exhibited.
The
The band that produces the constriction

THE STRICTURE.
145
at the femoral aperture is not entirely a
process from Poupart's ligament, but is
also formed by a tendinous band on the
fore part of the femoral sheath, where the
fascia transversalis passes in a funnel form
behind Gimbernat's ligament, to be inserted
into the pubis. The thin tendinous border
that descends backwards from Poupart's
ligament is attached to the front part of
the sheath of the femoral vessels; and any
attempt to push a director under this thin
border, anteriorly to the sheath, would
meet with great resistance; and, if it were
successful, its division would not suffi-
ciently liberate the sac from pressure.
Drawing 1. is a dissected view of the
fascia propria of a femoral hernia in the
male subject, with the inguinal canal and
spermatic cord exposed. An opening
has been made into the fascia, and the
director passed under it. The integuments
have been removed; but the superficial
fascia is left attached to Poupart's liga-
ment, and is seen separated from the fascia
propria by a piece of bristle. The sac,
covered by a layer of adipose and cellular
L

146
OPERATION FOR
matter, is seen under the director. The
stricture is not brought into view. The
drawing will serve to illustrate the pre-
ceding description of the operation.
In the male subject, no apprehension
need be entertained of wounding the sper-
matic cord, as it lies far away from the
parts forming the stricture; and the extent
of incision required for its complete di-
vision is much too small to bring into
danger the parts situated above Poupart's
ligament.
In inguinal hernia the incision may be so
conducted as to enable the surgeon to di-
vide the stricture either at the internal or
at the external ring. The opening in the
skin must be made higher than is usual in
the ordinary operation on a bubonocele.
The incision should begin at the neck of
the tumour, or where it seems to quit the
abdomen, and should be continued down-
ward for about an inch and a half. This
will lay bare the lower portion of the ex-
ternal oblique tendon, where it forms the

INGUINAL HERNIA.
147
ring. A small opening should then be
made in the tendon, just above the ring,
sufficient to admit the end of the director,
which will enable the operator to ascertain
if the stricture be at the lower or upper
opening. The size of the hernia, and the
length of time it has existed, will, in some
measure, serve to guide him; but he may
immediately decide the point by passing
the director downward under the edge of
the external ring, and feeling whether it
embraces the tumour firmly or not; or, by
making pressure on the swelling below,
he may feel if the fluid contents of
the tumour can be forced upward above
the ring, so as to distend the sac in the
inguinal canal. This point being decided,
if the stricture be at the lower ring, he has
only to pass his director under its margin,
and to divide it to a sufficient extent.
If the stricture exists higher up at the
neck of the sac, where it will be found in
the majority of herniæ of this description,
the opening in the tendon should be en-
larged to the extent shown in the second
drawing, for the purpose of passing the di-
L 2

148
INGUINAL HERNIA.
rector under the deeper stricture. The
lower margin of the two muscles will be
brought into view, with some of the de-
scending fibres of the cremaster. These
may be separated by disturbing the cellular
membrane with the end of the director;
and the instrument may then be intro-
duced under the transversalis muscle till
it reaches the stricture. In the subject, the
director, when introduced in this manner,
passes before the transversalis fascia; this
will diminish what little risk there may be
of wounding the peritoneum, and will carry
the knife further from the epigastric artery;
the tenuity, however, of this fascia, will,
perhaps, often allow the director to pass
beneath it. The instrument should be
depressed upon the sac, in
in order to
carry its point under the border of the
transversalis, which may be divided to the
extent required. This operation is more
difficult than the division of the stricture
in femoral hernia; the principal difficulty
lies in the accurate separation of the lower
edge of the internal oblique muscle, for the
easy passage of the director. Drawing II.

AT OPERATION.
149
represents the parts, with the instrument
passed under its edge. The stricture, how-
ever, is not so firm in inguinal as in femoral
hernia, and the introduction of the director
under the transversalis tendon will not be
difficult, where it is fairly passed up to the
neck of the sac before the attempt is made.
The steps of the operation will be much the
same in those smaller hernia, which are
lodged in the inguinal canal. When the
stricture is divided, a greater degree of
pressure will be required to return the con-
tents of a large inguinal hernia, on account
of the distance from the neck of the sac to
the bottom of the tumour, and especially
when the omentum forms a part of its
contents.
In small bubonocele, where the protru-
sion has scarcely reached the external ring,
and accompanied, as it commonly is, with
an imperfect descent of the testicle, the
same manner of operating may be followed.
I prefer making the opening in the ten-
don in the manner described in the drawing
to slitting up the external ring, as the
opening in the tendon will afterwards unite
L3.

150
UMBILICAL HERNIA.
more firmly if the ring be left entire, and
will not dispose the patient more to the
disease than when the operation is per-
formed in the usual way.
Umbilical hernia is, of all forms of this
disease, one that most requires the sac to
be preserved entire. Of all operations, it
is on the whole the least successful in
preserving life. The intestinal canal is
peculiarly susceptible of inflammation in
persons who are the subjects of umbilical
rupture; corpulent females are especially
the persons in whom it takes place; and
when strangulation occurs, inflammation
quickly ensues, and is generally rendered
more active by the operation.
The division of the tendinous margin
of the umbilical aperture is not difficult;
it requires care, on account of the extreme
thinness of the sac; and the operation,
therefore, consists in a cautious exposure
of the linea alba, where the tumour emerges
from the abdomen. The orifice of the sac
is rendered readily accessible at its upper

CASE.
151
part by the descent of the swelling towards
the pubes; the sac, when it emerges from
the abdomen, does not extend equally in
all directions, but gradually makes its way
downwards, in consequence of the weight
of its contents; and therefore, in old large
herniæ, though the aperture in the tendon
bears but a small comparison to the size of
the tumour, it is scarcely at all overlapped
by it at the upper part.
The case in which I first had occasion to
perform the operation was one of long
standing, with a large portion of irreduci-
ble omentum. The inflammatory symptoms
that came on after the operation were pro-
duced by a disposition to erysipelas, which,
had the sac been opened, would, in all pro-
bability, have assumed the form of peri-
tonitis. The following account of the
particulars are given in the words of my
dresser, Mr. Nunnelly.
CASE.
Sarah Pyer, aged sixty-seven, admitted
in the morning of the 21st February, 1832,
into Guy's, under Mr. Key, with a very
L 4

152
CASE.
large strangulated umbilical hernia. She
states that the hernia has existed for forty-
two years; that it occurred during her
second labour. She has never worn a truss,
but latterly, in consequence of the large
size of it, she has commonly worn a shawl
tied round her body. At night the hernia
usually became smaller, but never entirely
disappeared, and for a long time has never
been less than an orange in size. About
ten days ago she was not quite well, and
took some purgative medicine, which acted
very violently, during which the rupture
became larger and very painful; this sub-
sided spontaneously after two days, and she
became much as usual, with the exception of
a troublesome cough. Last night, in going
to bed, she felt the hernia larger and more
painful than usual, and was prevented from
sleeping by the pain. On attempting to
get up this morning, she was unable to
stand, and soon afterwards was conveyed to
the hospital. When admitted, the hernia
was very large, tense, and excessively pain-
ful on the least pressure, as was the abdo-
men above the navel; pulse small, feeble,

CASE.
153
and jerking; countenance anxious and de-
pressed; very cold and shivering; constant
nausea, vomiting, and eructations; bowels
opened yesterday. ad slaan
One P. M. Seen by Sir A. Cooper, who
made attempts to reduce it for some time,
and with considerable force, without suc-
cess; he wished every means to be tried to
return it without operation, saying, "that
it was a very unfavourable case for it, and
if tried, would probably end fatally."
Ice to be applied.
Eight P. M. Nausea and eructations con-
tinue; pain and tenderness have increased;
pulse 80, and very depressed. Attempts
were made by Mr. Key to reduce it by the
taxis, but no impression could be made upon
it: he therefore proposed to operate with-
out opening the sac, thinking, with Sir
A. Cooper, that if the peritoneum were laid
open, but little hope could be entertained
of her recovery. The woman readily as-
sented to the operation, saying," she would
rather be cut to pieces than have the taxis
applied, so painful was the hernia." A

154
CASE.
tranverse incision, about three inches long,
was made across the upper part of the
hernia, through the integuments; this was
met at a right angle by a longitudinal one,
two inches long, above the rupture; a di-
rector was then carefully insinuated under
the tendinous opening, and the stricture
divided without opening the sac. So much
of the hernia as was reducible was easily
and readily returned, its reduction being
evident to the bystanders by the gurgling
noise; the size of it was much lessened;
the woman received immediate relief, and,
on putting her hand to it, said, it had not
been smaller for two or three years.
R. Post horam unam, Magnesiæ sulphatis, ziij;
Magnesiæ Calcinatis, 3 ss. aquæ 3iss., et repet. 3ter
quaque horâ ; enema, 3j., Ol. Ricini injiciendum.
Twelve P. M. Is fast asleep.
22d, A. M. Has slept well; bowels have
been freely opened; has taken four doses of
the medicine; tongue rather furred; pulse
84, with more power; says she is much
easier, but on pressing the hernia she com-
plains of great pain; there is also some ten-
derness over the abdomen generally; no

CASE.
155
vomiting; it is less distended. Medicine to
be omitted, and to take-
Opii, g.. Antim. Tart. .; Hydr. Submur. g. 1. statim.
venæsectio ad 3 xiv.
P. M. Complains of acute pain on pres-
sure; the hernia is certainly smaller, and
not so tense as before the operation; very
thirsty; tongue drier; she has nearly lost
her voice, and has some catarrhal affection,
apparently from taking cold last night, in
going into the operating theatre.
Rep. Pilula.
23d, A. M. Slept, or rather dozed the
greater part of the night; blood drawn yes-
terday not inflamed; pulse 84, small and
jerking; pain in the hernia and upper part
of the abdomen very acute on the slightest
pressure; tongue covered with dry brown
fur; lies in a stupid state, half asleep; bowels
not opened since yesterday. Seen by Dr.
Cholmeley, who ordered her-
Opii, g. 1. Hydr. Submur. gr. 1. 4ter quaque horâ ;
enema Olei Ricini statim, with fomentations to the
belly.
P. M. Much the same; pulse has not quite
so much power; the bowels not being re-

156
CASE.
lieved by the castor oil enema, an injection
of house medicine (senna and salts) has
been thrown up, and produced one evacu-
ation. Pills to be omitted, as the opium
appears to affect the head. To
24th, A. M. Lies in a lethargic state; if
spoken to, rouses and answers, but immedi-
ately drops off again; says she is in no pain
while lying still, but if she attempts to
move, or is slightly pressed upon the hernia
or upper part of the abdomen, she com-
plains of great pain; tongue dry and red;
pulse 85, weaker; skin cool; bowels not
open.
R. Ol. Ricini, 3 vj.
P. M. Discharge of pus from the wound
not being healthy, the plaster removed and
a poppy poultice applied; pulse 88.
R. Calomel, g. ij.; Opii, g. i.
To be allowed arrow-root, with a small
quantity of wine in it. Catarrhal symp-
toms better.
25th. Bowels have been once opened;
pulse 80, compressible; sac softer; still com-
plains of much pain on pressure; tongue

CASE.
157
dry and red; head feels very stupid, and if
given any thing to eat, she falls asleep with
it in her mouth.
Emplastri Lyttæ. Rep. Pilula, Cal., Opio, horâ somni.
26th. Is rather better; head not quite
so heavy; pulse 74; tongue much the
same; skin cool; not so much pain on
pressure over the abdomen generally, but,
on the left side of the sac, there is an
erysipelatous blush of inflammation, with
a good deal of hardness; bowels have been,
during the night, much relaxed; evacua-
tions green and slimy.
alled
R. Mistura Acetos; enema Amyli. Tinc. Opii, mxx
injiciendum.
P. M. Purging continues.
Opii, g.j. statim. Aromat. c., Misturâ Acet.
2
27th. Bowels better; tongue much the
same; pain in the belly less; inflam-
matory blush gone, but the induration con-
tinues; pus discharged from the wound;
head better; pulse 70, good; very thirsty.
Rep. Pil. Opii, horâ somni. To have beef tea.
28th. Has had two good natural eva-
cuations; pain on pressure of the sac and
Diw betongue bos ou

158
STEPS OF THE
abdomen still continues, but in a less
degree; rather more sleepy than yesterday.
March 1st. Is not quite so well as
yesterday; has a little more tenderness;
bowels open, and tongue cleaning.
2d. Is better again to-day; less pain
and tenderness; pus good from the wound;
tongue better; pulse 80, and good; has
entirely lost the stupidity; says she can eat.
4th. Going on remarkably well; ten-
derness in a great measure subsided, with
the exception of the left side of the
belly, where the induration continues, and
threatens suppuration; it appears now en-
tirely confined to the subcutaneous cellular
membrane; appetite good. To have a
mutton chop, and ziv. of Port wine.
10th. Suppuration, with a little slough-
ing of the cellular membrane, has taken
place at the indurated part; there is a
free outlet at the umbilical opening; pulse
good; bowels regular, and tongue clean;
she eats well, and sleeps all night; no
hardness or pain of the abdomen.
20th. Is now able to get up; the
suppuration is diminishing; the parts are
strapped up and supported with a bandage;

OPERATION.
159
in every other respect she is perfectly well,
being, of course, rather weak. The hernia
is not at all tender, and is of the size it
has been for the last three years.
I have given this case at greater length
than may seem necessary; but such was
the unfavourable condition of the patient
at the time of operation, such the inflamed
condition of the parts within the abdomen,
as well as of those in the sac, and such the
tendency to inflammation, evinced by the
erysipelatous inflammation and subsequent
suppuration, that, from the result of hernia
operations which I have seen, I am con-
vinced that, had the sac been opened, the
patient, instead of recovering, would have
afforded another instance of the danger
and fatality attending the usual operation
in inflamed umbilical hernia.
In small umbilical hernia, a perpen-
dicular incision will be sufficient to expose
the tendon, especially when the abdomen
is not loaded with adeps: and there will
be some advantage in this simple form of
incision, as less suppuration will follow.

160
CONCLUSION.
The subcutaneous covering of the sac is
so thin, that there will be some risk of
opening it, unless the operator is careful.
The drawing, No. 3., represents the edge
of the tendon exposed, and the sac laid
bare by an incision made in its cellular
investment; but, in the operation, it would
be right not to expose the sac so much as
is here shown. The tendon alone ought
to be brought into view, and the surface
of the sac disturbed as little as possible,
on account of its extreme tenuity. Having
brought into view the tendon, and its edge,
where it bounds the opening, being felt with
the director, the operator may carry his
director under it, either by making a small
incision in the tendon at a little distance
from the margin, or may separate the edge
of the tendon from the sac, and then divide
it to the requisite extent. The former
method is shown in the drawing, and is
that which I have employed, as there is
less risk of wounding the sac. In this, as
in other forms of hernia, a very slight
division of the tendon is sufficient to li-
berate the contents of the tumour..cozioni

CONCLUSION.
161
It will be seen, from the foregoing ob-
servations, that the operation of excluding
the sac in the division of the stricture is
applicable to the majority of cases of
herniæ. It is not intended to advocate its
indiscriminate use in all cases. The dis-
cretion of the surgeon must be exercised,
in order to draw a distinction between
such forms of the disease as will admit of
its application, and those varieties in which
it could not or ought not to be employed.
My object is, to recommend an operation
that will render strangulated hernia a less
fatal disease than it has proved to be under
the most skilful treatment; and if, in the
practice of other surgeons, it be successful,
my end in writing these pages will be
accomplished.
THE END.
M

121
ati stesovi
aib ed
Бе
LONDON:
Printed by A. SPOTTISWOODE,
New-Street-Square.
Ines
943
bne
bodailamosos


Dr $ 1.
C.J. Canton del,& lithog.
Printed by G Hullmandel.

DRAWING I.
This drawing represents a femoral hernia
dissected, in order to show its coverings, and
the mode of passing the director. The super-
ficial fascia coming from Poupart's ligament is
partly removed, to show the fascia propria; a
portion of bristle being passed under it, to se-
parate it from the latter fascia. An incision has
been made into the fascia propria, for the
passage of the director under the stricture.
The stricture is not brought into view. The
inguinal canal is opened, to show that the cord
is not endangered in the division of the stric-
ture.
See page 129.
M 2

I UZIVARC
30 obom


Drg 2.
C.J. Canton del et lithog
Printed by Hullmandel

DRAWING II
Is intended to show the opening in the tendon
of the external oblique muscle, by which the
director can be passed either under the external
ring, or under the edge of the transversalis
muscle at the inner ring. The edge of the
muscle brought into view upon the director is
the margin of the internal oblique, and does not
represent the stricture, which is concealed from
view. The explanation of the operation on in-
guinal hernia will be found at page 146.

Dr$2

DRAWING II.
Is intended to show the opening in the tendon
of the external oblique muscle, by which the
director can be passed either under the external
ring, or under the edge of the transversalis
muscle at the inner ring. The edge of the
muscle brought into view upon the director is
the margin of the internal oblique, and does not
represent the stricture, which is concealed from
view. The explanation of the operation on in-
guinal hernia will be found at page 146.



Drs 3
C.J. Canton del et lithog.
Printed by C Hullmandel.

DRAWING III.
Is a view of an umbilical hernia dissected. The
membranous investment of the sac is turned
aside, to show the upper part of the sac and the
margin of the tendon forming the aperture
through which the hernia passes. The director
is passed through an opening in the tendon, for
the purpose of dividing the stricture.
page 150.
See

Drs 3.
*
Brinted

DRAWING III.
Is a view of an umbilical hernia dissected. The
membranous investment of the sac is turned
aside, to show the upper part of the sac and the
margin of the tendon forming the aperture
through which the hernia passes. The director
is passed through an opening in the tendon, for
the purpose of dividing the stricture, See
page 150,



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