No. 366.

LONDON, SATURDAY, SEPTEMBER 4. [1829-30.

LECTURES ON SURGERY,

MEDICAL AND OPERATIVE,DELIVERED AT

St. Bartholomew’s Hospital;

BY MR. LAWRENCE.

LECTURE LXXXIII.

Hernia, continued.-Treatment of Irre-ducible Hel’nia.-Strangulated Hernia ;Symptoms; Treatment; Operation.-Inguinal Hernia.

Treatment of Irreducible Hernia.- Whena rupture is rendered it-reducible, either byincrease of the bulk of the parts which aieprotruded, or by their adhesion to the sac,the patient is exposed to all the incon-veniences of a permanent tumour, whichprobably increases regularly, and to the con-stant risk of the occurrence of strangulation ;hence it is very desirable to convert a her-nia from the irreducible to the reduciblecondition, even if nothing more than thatcan be done. You may sometimes succeedirt effecting the return of a hernia, if it hasnot been long unreduced, by putting the pa-tient on low diet, exhibiting active aperientmedicine and applying cold to the swelling,so as to diminish the bulk of the protrudedparts; and this has been attempted with aview of accomplishing the object, even afterthe hernia has remained irreducible for a

long time. You will of course understandthat there is no chance of effecting the returnof herniae which are rendered irreducible byadhesions ; but when we cannot understandexactly the nature of the obstacle to reducetion, it is right to make an attempt to returnthe hernia if it has not been long in theirreducible state. In adopting measures ofthis kind, you must bear in mind the state ofhealtb of the individual, and not adopt any Imeasures so powerful or so serious as to

run the risk of injuring his health.It may be a question, whether you would,

under any circumstances, think it right to

propose an operation for accomplishing thereturn of the protruded parts in an irre-ducible hernia, when they cannot be replacedin any other way ; whether, supposing theobstacle to depend on adhesions, you wouldthink it right to open the hernia, separatethose adhesions, and carry back the partsinto the abdomen. Now, all the objectionswhich I mentioned to you as applicable tothis proceeding for the radical cure of redu-cible hernia, are applicable to the operationin this case also. An irreducible rupture isonlv an inconvenience and a source of riskto the patient, but the operation which youperform immediately endangers his life. Asa general rule, therefore, the operation inquestion is not admissible under such cir-cumstances ; though we cannot, perhaps,lay down absolutely that it should neverunder any circumstances be performed. Iremember the instance of a gentleman whohad an irreducible omental hernia. As theneck of the sac was constantly kept open bythe protruded omentum, he was liable, onany exertion, to have a portion of intestinedescend; the intestine was then subject topressure ; at those times great pain wasexperienced by the patient, who becamesick and was obliged to go to bed and remainthere till the intestine could be returned,suffering very considerably till this objectcould be accomplished. Now, this was afine young man, just at the active periodof life, and he found the inconvenience ofthis rupture so great that he was resolvedto attempt getting rid of it, and, in fact, anoperation was performed. It was found tobe an adherent omental hernia as was antici.

pated ; the adhesions were separated, andsome portion of the omentum was removed.This gentleman nearly lost his life in conse-quence of the inflammation that supervenedafter the operation. It is a proceeding,therefore, only to be adopted very cautiouslyat the urgent request of the patient, andwhere there is inconvenience of the mostserious kind, in consequence of the irreduci-ble state of the rupture ; and, indeed, evenunder such circumstances, it is not to berecommended to the patient, it is only to beperformed if he should absolutely require it.Under other circumstances, the patient

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should content himself by having the tumour Bsupported as much as possible by a suspen-sory bandage. It does not always happenthat a hernia increases to an enormous size,even if no bandage should be worn. I am

acquainted with a member of our own pro-fession, who has had a large scrotal hernia fora number of years; it was originally a redu.cible hernia, but although he could returnthe parts into the abdomen, so much pain Iand inconvenience were produced that hecould not bear them up, and was obliged to

take the truss off and leave the parts to z,themselves. Thus the hernia remained down,and though he has been employed since thattime in a very active life, and been in thehabit of riding about in the country withthis scrotal hernia, and it has attained a veryconsiderable magnitude, it does not inter-fere with his occupation. Other instanceshave sometimes been seen, particularly infemales, who have not been willing to men-tion the existence of a complaint of thiskind, where no truss has been worn, andwhere still the hernia has not enlarged toany great extent, or been attended with anydanger.

Strangulated JaMM.—The most danger-ous condition of a rupture is that of strangu-lation, or incarceration, which are synony-mous terms ; that is, where the protrudedparts experience such a degree of pressurefrom the sides of the opening, through whichthey pass out of the cavity of the abdomen,as not merely to confine them in that situa-tion and prevent their return, but to suspendtheir functions, to produce inflammation inthem, which is propagated to the contentsof the abdomen generally, and which in avery short time brings the patient into acondition of great danger. The pressurehere, or rather the part which produces thepressure, which confines the protrudedviscera, and prevents them from beingreturned, is technically termed the stricture-the contracted portion of the opening;and this stricture either is produced by thesides of the opening through which the vis-cera are protruded, or that thickened andhardened state of the sac which I describedto you in the last lecture. So far as the

pressure is concerned, it is immaterial whe-ther it is produced in one or the other ofthose ways ; indeed the effects of strangula-tion or incarceration are the same whateverits cause may be. The immediate effects

produced by the stricture, are on the partswhich are surrounded by it ; changes arethen induced in the protruded viscera belowthe situation of the stricture, and the effectsof the pressure are also propagated in theother direction to the intestine situatedabove the stricture, and to the other con-tents of the abdomen. Further, this pressuresuspends the functions of the parts tha1

may be protruded; and as those are gene-rally some portion of the alimentary canal,of course a stop is put to the transmission ofthe alimentary matter. The first or imme-diate effect of the stricture on the partswhich it embraces, is a mechanical impres-sion on them, as if a thread were tied roundthem ; and when they have been subject fora time to the operation of the stricture, theimpression remains on them even after theyare taken out and put up as a preparation.Here is a preparation of that kind ; this is aportion of the intestine and mesentery; thepart producing the stricture has been takenaway, but you see very plainly the mark orindentation which it has left. Here is anexample of a case in which the bowel is verymuch distended above and below the stric-ture, and reduced at the point where it hasbeen girt round by this band, to the size of alarge writing-quill. The stricture has beenremoved, and there is nothing to preventthe parts from resuming their natural situa.tion, but still they remdn in that state,appearing, as you see, to be almost cut

j through.Now, when you see this considerable me-

chanical effect produced by the pressure ofthe stricture on the protruded parts, youwill not be surprised at finding, where aportion of the intestine is surrounded by atight ligature of this kind, that the coatsundergo ulceration, which sometimes nearlyseparates the bowel at the point where it isthus compressed. Generally speaking, how-ever, the ulcerative process will go throughthe internal mucous membrane and the mus-cular coat, but will not penetrate the serouscoat ; the serous coat resists the ulcerativeprocess longest, but in some cases there willbe made an opening directly through it.This is a specimen in which there is a bitof straw introduced into the ulcerated open-ing, and it goes completely into’ the cavityof the abdomen. Here is another, wherethe serous coat is completely perforated, sothat you see an opening of some size intothe abdomen, where the stricture has beensituated. This is produced by ulceration inan incarcerated hernia, but it is by nomeansuncommon to find that the internal andmiddle coats are ulcerated, the serous mem-brane remaining entire.

If the protruded parts are thus firmlypressed upon, the circulation through thevessels of the parts below the stricture be-comes impeded ; the vessels become dis-tended, particularly the veins; the coats ofthe intestine are thickened, and the veinsbeing filled with dark-coloured blood, thewhole is very considerably discoloured; thesame kind of effect is produced on the pro-truded parts as would be produced upon theleg or arm, if you tied a ligature roundeither of them. There is then an impedi-

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ment of the circulation, a distention of thevessels, a thickening of the coats, and alivid discoioration of the intestine. Thisdiscoloration is often very considerable ; theintestine assumes a deep choeolate-b!0<vncolour, or a dark livid tint, hardly distin-guisliable from black. When you see fromthe first a portion of bowel which has un-dergone this change in a case of hernia,you are inclined to imagine that it is mor-

tified ; but this is merely an appearanceproduced by the pressure and the interrup-tion of the circulation.

Further effusion takes place from thesurface of the protruded parts. Generally Ia serous, bloody, reddish-coloured fluid, is Ipoured out into the sac, and we meet withsuch a fluid when we open it in performingthe operation for strangulated hernia. Some-times there is a considerable quantity of thisfluid effused, sometimes a small quantity ;sometimes you meet with hardly any at all.Effusion of coagulating lymph may also beproduced from the surface of the bowel andomentum. If the pressure is not sufficientto interrupt the circulation, it may have theeffect of exciting inflammation ; coagulat-ing lymph will then be effused, and thus theprotruded bowel or omentum will becomeagglutinated to the sac. This adhesion,however, is so slight, that you can separateit with your finger, or with the handle ofthe scalpel ; it is a different kind of adhe-sion from that which takes place between.the sac and the other parts, at the end of aconsiderable length of time. The effectsproduced in the cavity of the abdomen arethose of inflammation, excited in the partsimmediately embraced by the stricture, andpropagated by continuity along the surfaceof the serous membrane generally, where itproduces the ordinary effects of peritonealinflammation. The functions of the pro-truded part are arrested, so that if any partof the bowels be protruded the costiveness isproduced; in consequence of this circum-stance the alimentary canal, above the situ-ation of the stricture, becomes greatly dis-tended. No doubt, secretions take placefrom the mucous surface of the canal, in

consequence of the irritation excited in it

by inflammation; and we find, when wecome to examine the bodies of persons whodie under such circumstances, that the in-testine above the stricture is enormouslyincreased in size, and filled with a fluidmatter and flatus, while, on the contrary,that part which is below the stricture, is inan equal degree diminished, contracted, andfree from inflammation. The interruptionof the functious of the bowels and the cos-tiveness are easily explained in cases wherethe stricture is so considerable as I havejust described-where the bowel is firmlyembraced, and its sides brought into con-

tact by the stricture; but these symptomsare also observed under other circum-stances.

There are some instances of very smallhernias, where only a portion of the dia-meter of the intestine is included in thestricture, so that there would be a passage,still left for the contents of the alimentaryIcanal; yet in those instances there is cos-tiveness, and the functions of the canal areinterrupted. There are also instances ofstrangulated omental hernias, where no

bowel is protruded at all, and where theconsequences are the same as where thehernia consists of intestine. So that thesuspension of the functions of the aliment-ary canal, and the costiveness, are not tobe ascribed merely to the mechanical stateof the stricture, but to the inflammation ofthe protruded parts, and in the cavity ofthe abdomen.

Symptoms.-From these effects of thestricture, you will easily see what the symp-toms must be which are found in a case ofstrangulated hernia. Costiveness, whichdoes not yield to the exhibition even of themost active aperient medicines. -Sickness,either nausea or actual vomiting. Andwhen the strangulation lasts for a consider-able time, it appears that the contents ofthe bowels pass in an unnatural direction ;the peristaltic action of the bowels is in-

verted, and their contents are ejected fromthe mouth-not simply those of the sto-mach, but a matter is ejected which is con-sidered to be f{Bca!, and this is called ster-coraceousvomiti2,tg-. It is doubtful whetheractual fasces are ever ejected in this way,but at all events, the contents of the smallintestines, consisting of a liquid substanceand tinged with bile, are certainly thrownup in the protracted states of strangulatedhernia. There is pain in the swelling ;tenderness on pressure first, then consider-able pain : this pain is most considerable atthe neck of the sac, just where the parts areembraced by the stricture ; but graduallyextends over the whole abdomen, in con

sequence of inflammation passing to it fromthe stricture ; distention of the abdomentakes place, and indeed all the symptomsthat belong to a case of peritonitis. Theabdomen faels firm and tense as well as

painful. There is a quick, but at the. sametime, small and hard pulse, a white and drytongue, sense of feebleness, coldness of theextremities, and thirst. These are the kindsof symptoms that are observed in cases of

strangulated hernia.Now, all cases of strangulated hernia do

not present exactly the same assemblage, orthe same degree of symptoms ; there is aconsiderable variety. You sometimes havethe symptoms coming on very rapidly,arising quickly to a high pitch, and changes

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of a very serious nature taking place in theparts within a short time. In other in-stances, the symptoms come on almost in.sensibly ; they proceed very slowly, andthe strangulation exists for a considerablelength of time without the occurrence of anyserious or marked alteration in the parts.The inflammation, therefore, which occursin cases of strangulated hernia, may, as

in other cases, be either acute or chronic.If a hernia forms suddenly in a youngand robust person, from some accidentalcircumstance, the progress of the case willbe very acute ; the tumour from its com-’ mencement is exceedingly painful; painand tension come on in the abdomen, andthe local changes go on very rapidly : withina few hours the intestine frequently becomescold, and if it be not liberated, mortificationwill speedily ensue. In other instances,where a hernia has existed for a consider-able time in elderly persons, more par-ticularly if it is a large hernia, the symp-toms of strangulation come on very slowly.In the first instance, perhaps, obstructiontakes place in the bowels, and gives rise tothe state of strangulation of the intestine.The symptoms are rather referable to theobstruction in the passage of the contentsof the alimentary canal than to pressure andinflammation excited by it; and several

days will go on without their assuming avery formidable character. The pain in thetumour is not very considerable, there islittle pain and no tension in the abdomen ;and thus at the end of many days, the stateof the patient may be less dangerous thanthat of another after the expiration of a fewhours. I operated on a gentleman in theevening, in whom the hernia had becomestrangulated in the morning of the same day;he was a young man of full habit; the symp-toms were very violent, there was intensepain all over the abdomen; the tumour con-tained intestine only, which was of so deepa colour, that I think an inexperienced per-son would have said it was mortified. In Ithe case of an old woman now in the Hos-pital, the operation was performed at theend of 36 hours after the strangulation hadtaken place; yet the intestine was by no! imeans much altered in colour, and the symp- Itoms were not very violent. In the case of iacute strangulation, the mischief consists ofacute inflammation of the tumour, producedby the pressure of the stricture, immediatelyover the parts protruded, and spreading overthe abdomen. In the case of chronic stran-gulation, the symptoms are mostly referableto obstruction in the alimentary canal,-in-duced in some measure by the stricture, toa confined state of the bowels, the gradualcirculation of their contents, and the incon-venience arising from such accumulation.

y’eMC.&mdash;The first object in the treat-

ment of strangulated hernia is, of course, toreplace the parts that are pressed upon bythe stricture-to return the protruded vis-cera into the cavity of the abdomen ; if youcan accomplish this, the danger of tbepatientis at an end. We naturally try, in the firstinstance, to return the protruded parts bypressure with the hand; and this process iscalled in books the operation of the taxis.When we perform this, in the case of a her-nia which is either strangulated, or on thepoint of becoming so, we of course placethe patient in such a position, and proceedirt such a manner, as will give us all possibleadvantages in respect to the return of theparts. We place the patient in the hori-zontal position ; for the contents of a rnp-ture in a reducible state, will return whenthe body is in the horizontal position. It isof advantage to have the pelvis a little ele-vated, and the trunk of the body slightlyincurvated, so that the abdominal musclesshall be relaxed ; and in those ruptures thatpass out at the inguinal canal we relax themuscles of the pelvis, so as to diminish thetension at the opening through which theparts are protruded. Then being at theside of the patient, we embrace the tumourwith one hand, and subject it to a generalpressure, employing the finger and thumbof the other hand at the neck of the tumour,in order to get the parts into the abdomen.We press the tumour gently, varying thedirection of the pressure according to cir-

cumstances, bearing in mind in each in-stance the course which the protruded partsmust have taken, and giving our pressure adirection accommodated to the course of the

rupture. In doing this, it is necessary to

proceed gently, not to grasp the parts vio-lently, nor to push them with considerableforce, nor to squeeze them against the bonyparts of the parietes through which the pro-trusion has taken place ; for, by so doing,we should add to the mischief, and probablyin that way fail to accomplish our object.We should proceed with particular cautionwhere the symptoms of strangulation haveactually come on. To say the truth thereturn of the parts by the taxis, as it iscalled, is more applicable to that state of arupture which immediately precedes incar-ceration, than to the state of incarcerationitself. When the parts become inflamed,and the inflammation is spreading to the ab-domen, we have little chance of returningthem into this pressure ; but in the state

which exists just before this, we may ac-complish the object. Any thing like force,any thing like continued efforts, after theparts have become inflamed, must, for evi-dent means, be exceedingly injudicious.No doubt a great deal of mischief is doneby attempts of this kind, and by their inju-dicious repetition, as well as by the repeat-

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ed trials made by the different persons,when they are called in consultation upon acase of this kind. No good whatever canresult by three or four or five persons try-ing to return the hernia ; indeed, the thingis so simple, that whatever can be done inthat way can be done by one person ; and ifhe does not succeed, supposing the attemptto be judiciously made, there can be no goodobject answered by any other person makingit. Dessault was so impressed with the

prejudicial effects of pressure upon a stran-gulated hernia, that he entirely prohibitedall such attempts in the H4tel-Dieu. When,therefore, a person was brought in with

strangulated hernia, he confided entirely inother means; he would not allow any pres-sure whatever to be made, until the in-flammation was completely overcome, andthe parts brought into a situation in whichthey would almost return of themselves. I

merely mention this, not with a view thatyou should abstain altogether from attemptsof that kind, but to satisfy you that the pre-judicial effects must have been very great tohave induced so great a surgeon as Dessaultto lay down such a rule. If you cannot gainyour object then by the taxis, you must en-deavour to reduce the inflammation ; and ifyou can accomplish that, there will be littlefurther difficulty; if you can bring the parts iwhich are subject to pressure into a natural

I

state, if you can relieve them from the in-

jurious effects of the stricture, the herniawill he easily reduced.The first measure that is naturally resort-

ed to in a case of this kind, is the abstrac-tion of blood-venesection ; and a patientwith strangulated hernia may, in general,be safely bled to some extent. We cannotassert that bleeding is proper in every case;but it is usually a proper measure, and it isto be employed, unless there should be somecontra-indicating symptom. The danger ofa patient with strangulated hernia is frominflammation ; the danger of failure in theoperation, if it comes to be performed, isfrom inflammation, and therefore the lossof blood in the early period of the stran-gulation cannot be otherwise than bene-ficial. A rupture is often returned after thepatient has been bled, more particularly ifthe bleeding produces syncope. The warmbath is also a powerful remedy; it shouldbe as warm as the patient can well bear it;you should keep him there for some time,till it produces a state approaching to faint-ness, and the rupture can often be then re-turned. The application of cold to the tu-mour which reduces the bulk of the pro-truded parts, and diminishes inflammationin them, is also a very proper measure to beemployed. It may be used after a personhas gone into the warm-bath; if this has notbeen successful, ice may be applied to the

tumour, pounded, put into a bladder, andlaid upon the parts; or you may employice-water at 32&deg; ; or you may employ, if youhave no ice, a freezing mixture made withsalt and water. These are, perhaps, thethree most important measures : the loss of

blood, the warm-bath, and the applicationof cold to the swelling.There is another powerful measure which

has been much confided in, and that is theexhibition of tobacco in the form of injec-tion. Sometimes tobacco-smoke has beenthrown up by means of an apparatus for thatpurpose, something like a pair of bellows,with a glyster-pipe at the end of it, and acontrivance for the burning of the tobacco.This, however, is uncertain in its operation;and, therefore, when tobacco is employednow, it is used in the form of injection-adrachm of tobacco to a pint of boiling water ;and half that quantity is to be thrown up,and if it does not produce its peculiar effectson the system, which consists in a greatdiminution of the force of the actionof the heart, and general relaxation ofthe powers of the system-if those effectsare not produced within a quarter of anhour or twenty minutes, the other halfmay be injected. During that state of

depressed arterial action, and depressednervous energy, which tobacco causes when

employed in this way, strangulated herniais often returned. You must be aware,

however, that this a very powerful agent onthe system, and that its employment is at-tended with some degree of risk. Instanceshave been known, in which the tobacco-

injection seemed to have proved fatal,therefore it must be employed with greatcaution ; and, indeed, in consequence of itsviolence of operation, I think it is now (andperhaps judiciously so) much less frequent-ly employed than the means I have alreadymentioned. Although there is no doubtthat, in many instances, the influence of to-bacco on the system has produced the returnof the hernia, when the operation seemedalmost inevitable.The costiveness which prevails at the

commencement, and throughout the stran-gulation, has materially led to the exhibi-tion of purgative medicines; but it is obvi-ous that these are not suitable, when stran-gulation is fully formed. When inflamma-tion within the cavity of the abdomen hastaken place, when vomiting is excited bywhatever is put into the stomach, when thealimentary canal above the stricture is dis-tended and filled with liquids and flatus, youcannot expect to benefit a patient by the ad-ditional irritation which the exhibition ofpurgative medicines produces ; they are,therefore, only to be used in the very com-mencement, where you may expect to pro-duce a return of the protruded parts by an

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active aperient, and more particularly in thecase of chronic strangulation. In -the caseof an old rupture, where the symptoms ofstrangulation come on slowly, and wherethere is reason to suppose that obstructionin the alimentary canal is their primarycause, a brisk purgative medicine will some-times accomplish the purpose we wish.-Under such circumstances calomel and jalap,or calomel and colocynth, are suitable pur-gatives.

Operation.-In failure of the means thatI have now described to you, we must haverecourse to the operation. The state of a

patient with a strangulated hernia, is oneof very urgent and eminent danger. Youmust employ, therefore, at once means ofan active kind, and when they fail, youmust lose no time in resorting to the onlymode of relieving the patient that re-mains-the performance of the operation.There is no case in which inert treatmentand injudicious delay are more prejudicialthan in that of strangulated hernia. You

must, of course, reflect beforehand on themeans you may find it necessary to adopt;on this account you should be prepared toemploy measures of the most active kind asquickly as possible ; and as soon as theyhave failed to produce the desired effect,then you must lose no more time, but resortto the operation. If active means havefailed, you cannot expect that any good willresult, by waiting to see if any good effectwill be produced from their repetition, orfrom the employment of less active mea-sures ; and the state of a patient with stran-gulated hernia is never stationary-it is al-

ways getting worse, therefore the longeryou delay the operation, the more is thechance of recovery diminished. A greatproportion of the operations for strangulatedherni&aelig; do well when they are performedearly, and a great proportion of them turnout unfavourably when they are delayed.Heretofore it used to be the practice to gothrough a round of all the means that couldbe devised for the reduction of strangulatedrupture, before proceeding to the operation,and cases of rupture then turned out verybadly. It is now the practice, on the con- -trary, to use active means at once, and whenthey fail, to proceed immediately to the ope- iration ; and there is, proportionately, a fa-vourable change in the results of the opera-tions. For mv own part, I should say that Ihave many times seen the operation per-formed too late, and that I do not know thatit has ever come within my observation to Isee a case that I should say was operated ontoo soon.

Inguinal Hernia.&mdash;Inguinal hernia, or,as it is technically called, bubonocele, takesplace through the opening hi the abdomen, Iwhich transmits the spermatic chord in the

male, and the round ligament in the female.The parts which are protruded in this wayform a tumour in the groin, and if that tu-mour increases, it descends into the scrotumin the male, and into the labium pudendi inthe female, in which latter case it is called,in the male, scrotal hernia. Inguinal andscrotal bernip, therefore, are so far thesame, that a scrotal hernia has been an in-guinal hernia originally; it is merely aninguinal hernia extending lower down intothe scrotum.

In a case of inguinal hernia, the parts areprotruded through the same opening, butthey are not protruded in all cases m thesame manner. In the majority of instancesthey pass over the spermatic chord, andalong the whole course of the canal, andtherefore they take precisely the same

course which the spermatic chord does. Thespermatic chord goes out of the abdomen,not in a straight but in an oblique direction.It first passes out nearly midway betweenthe anterior superior spine of the ilium andthe symphysis pubis ; it then runs obliquelybetween certain portions of the abdominalmuscles, and passes out over the pubis atthe ring, in the external oblique muscle.Thus it is directed obliquely from abovedownwards and forwards ; and the greaternumber of inaninai hernia pursue this

course, that is, tne pa&middot;ts are first protrudedin the space midway between the bonyparts I have just mentioned ; they run be-tweea the muscles, and then come out ofthe ring in the external oblique muscle.The neck, or upper part of the sac, is ob-lique, passing in the same course with thespermatic chord through the inguinal canal,and the hernia, in that case, follnwing pre.- cisely the course of the chord, is protrudedon the outer side of the epigastric artery,so that this artery is situated on the innerside of the sac. This kind of rupture iscalled externa.l inguinal hernia, the partsbeing protruded on the outside of the epi.gastrib artery. This is a specimen of a rup.ture of that kind, and here is the epigastricartery running along the inner edge of themouth of the sac.The neck of the sac of a hernia of this

kind is just as long as the inguinal canal;for it is the part embraced between the ab-dominal muscles, and lying in the space thatintervenes between the upper and the loweropenings of the inguinal canal. That is thestate of the parts when the rupture is firstformed ; but after it has lasted for sometime, the gradual weight and pressure ofthe protruded parts bring the upper part ofthe hernia in a line with the lower part, sothat after a certain time the neck of the sacloses its obliquity, and that which was theneck is nearly at the bottom. As the partsin this case are protruded immediately over

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the spermatic vessels, they pass betweenthe cremaster muscle and those vessels, andbelow that covering which the tunica vagi-nalis gives to the chord and the spermaticvessels. The peritoneal sac, therefore, iscovered externally by the cremaster muscle,and by the tunica vaginalis communis. Inthis form of the rupture then, you have, inaddition to the usual coverings, an externaland thickened covering, made by the tunicavaginalis communis and the cremaster mas-cle. Here is a dry preparation showingthat; here are the fibres of the cremastermuscle running quite distinctly over thehernial sac; here is the hernial sac ; hereis the hernia and the testis below ; here isthe hernial sac laid open within, and theseare the external coverings which are derivedfrom the sources I have mentioned.

The hernia comes directly over the sper-matic chord, which is thus generally situatedat the back of the hernia. In old herniacthe pressure separates the constituent partsof the chord, and the swelling insinuatesitself between them, so that you may havethe vessels and nerves on one side and thevas deferens on the other; here is a speci-men of that sort ; here is a specimen of an-other case, where you see all the parts se-parated in that way; but in a small hernia,the spermatic chord is situated along themiddle of the back of the hernia.This then is the course which .the hernia

takes in the more common species, whichas I have mentioned is called external in-

guinal hernia, in consequence of the contentsof the abdomen being protruded outside theepigastric artery. There is another kind ofhernia which does not come through theinguinal canal, but is forced directly out

through the external ring, on the inner sideof the epigastric artery, so that in this case,the artery is situated on the outside of thehernial sac, this is called an internal ingui-nal hernia. Now in this case, in which thehernia comes out directly through the exter-nal ring, the neck of the sac is not at all

oblique, even at the very commencement;the opening is directly and immediatelyinto the cavity f the abdomen, and there isnot that long oblique neck which is observedin the case I have just described to youHence those two kinds of hernia have beencalled by Sir Astley Cooper, oblique anddirect inguinal hernia. The latter kind ismuch less frequent than the former. I donot know the exact proportion ; some havesaid in the proportion of one to five : but Irather think the direct inguinal hernia arenot so numerous, perhaps they do not occurmore than in the proportion of one to ten,or even fifteen. In this case, the hernialsac is situated on the outside of the sper-matic chord, and not covered by the cre-master muscle or tunica vaginalis.

There is another modification of the ex-ternal or oblique inguinal hernia; you mayhave the parts protruded at the superior orinternal aperture of the inguinal canal form-ing a tumour, but not coming out at theexternal ring ; there the hernial tumour iscontained within the inguinal canal. Butthe parts may not only be protruded andconfined in that situation, but they may bepressed upon by the margin of the openingthrough which they have been protruded,and become strangulated. In this varietyof the tumour the hernia is generally verysmall, and covered externally by the aponeu-rosis of the external oblique muscle, so thatthe boundaries of it are not very distinctlydefined. If such tumours are pressed much,they may pass out of the external ring andbecome common external inguinal hernia:.This is a specimen of that kind which Ishowed you before, for the purpose of satis-fying you that hernise may take place with-out producing an external tumour. If I donot mistake, this was taken from a patientwho died in consequence of the existenceof the hernia not being ascertained duringlife from the smallness of the swelling,though a careful inquiry was made, andcareful examinations instituted, in thevarious situations of hernia, in order to seewhether there was any such protrusion.

This preparation points out to you thenecessity of a cautious examination of allthose parts through which hernias may pro-trude, in the case of persons labouringunder such symptoms as may be producedby strangulated intestine ; you must notmerely ask a patient whether any tumourexists in such instances, but you must

actually feel with your own hand, and pressin every situation, in order that no smallrupture may in possibility escape your ob-servation. There is another kind of cautional.3o to be observed, rather of a contrary kindto this, in cases of herniae; that is, youmust be aware that inflammation of thebowels or inflammation of the cavity of theabdomen, may take place in a patient whohas hernia, and the state of that individual

, may present to you a puzzling combinationof circumstances, in which you find it diffi-cult to determine, whether the hernia is thecause of the symptoms which the patientlabours under, or whether the symptoms

, are not independent of it. You may haveaff2ctions of that kind occurring in an in-dividual with a rupture, just as it mightoccur in a person without a rupture;but when such symptoms exist, where youhave costiveness and inflammation of thebowels, the first impression on your mindwill be, that the rupture is the cause ot thesymptoms, but it is not necessarily so. Inorder to determine this point, itis necessaryto attend very carefully to the origin and

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state of the tumour ; to see whether the

symptoms commenced in it and extendedto the’abdomen, or whether they commencedin the abdomen, the tumour remaining freefrom pain, tension, and the other conditionswhich belong to strangulation. The stateof the tumour when you make the examiiia-tion, and the point at which the symptomscommenced, are the two circumstanceswhich will probably guide you in deter-

mining the point in question in instancesof that kind.

LECTURE LXXXIV.

Inguinal Hernia, resumed.- Proper Situa-tion for a Truss.&mdash;Operation for Sti-an-gulated He)-nia.-.drtificial,4nus.-Pro-lapsrcs of Intestinefrom Artificial Anus.&mdash;Stercoral Fistale.-Hernia Congenita.- Symptoms and Diagnosis of inguinalHernia.

I BEGAN to speak in the lastlecture of ingui-ned hernia or bubonocele ; I observed thatthere are two varieties of that rupture, onein which the parts are protruded throughthe inguinal canal, entering at the superioror internal, and making their appearance atthe external or inferior opening, namely, theaperture in the tendon of the external

oblique, first appearing as a tumour in thegroin, and then gradually extending into thescrotum. I mentioned that it is called exter- Inal inguinal hernia in consequence of itsbeing protruded on the outer side of theepigastric artery ; that the parts are pro-truded directly over the spermatic chord,between it and the cremaster muscle, andthat the peritoneal sac receives an externalcovering from the cremaster and the tunicavaginalis communis. I stated to you that itwas also called oblique inguinal hernia, inconsequence of its having, particularly inthe commencement, an oblique directionfrom below upwards and outwards. I statedthat there is another kind of this rupture inwhich the parts are first protruded at thesuperior or internal aperture of the inguinalcanal, and do not pass out at the inferioraperture, and that they may be even strangu-lated in this situation ; that in that case thehernia is, of course, situated in the groin,and is covered by the external oblique. Thisis a specimen of a rupture of that kind, inwhich, however, a portion of the tumour issituated in the way that I have mentionedto you, in the inguinal canal between thesuperior aperture and lower opening of thatcanal, and another portion has passed throughthe inferior opening and descended into thelabium pudendi. I mentioned to you thatin the other variety of inguinal hernia theparts are protruded directly through the ex-ternal ring; that they pass out of the ab-domen on the inner side of the epigastric

artery, so that the artery is seated on theexternal side of the mouth of the sac, andthat this is called internal inguinal hernia,or direct inguinal hernia, inasmuch as theparts come out in a straight course. Now,in the latter case, that is in the diiect orinternal inguinal hernia, which is the leastcommon of the two kinds, the hernia neverobtains a considerable magnitude, for it

pushes before it, and is covered by the fasciatransversalis, and thus it cannot increase toany great extent.Now, these differences are rather impor-

tant in reference to certain anatomical points,and, more particularly, as to certain ques.tions that arise in executing particular partsof the operation.

P1’oper Situation for a Truss.&mdash;The pro-per place for the application of the pad of atruss in a reducible inguinal hernia, is thepart at which the viscera are first protrudedfrom the abdomen. In the case, therefore,of the most common species, that is, the ex-ternal or oblique inguinal hernia, the situa-tion for the pad of the truss in the incipientstate of the complaint is midway betweenthe angle of the pubis and the anterior

superior spine of the ilium, where theviscera are first protruded. In the case ofdirect or internal inguinal hernia, the padmust come immediately over the ring of theobliquus externus, that is immediately abovethe angle of the pubis. But in either caseyou have to ascertain, by pressure with yourhand, the exact place where the viscera pro-trude, and that is the point to which the

pad of the truss is to be applied. In takingthe measure of a patient for a truss, you haveto measure from the point at which the partsare protruded in a circular direction roundthe body; and a string carried in that waywill be proper enough for the measure to begiven to an instrument-maker. It will bewell, however, to mark the place where thepad is to press upon the opening in the onecase, midway between the anterior superiorspine of the ilium, and the angle of thepubis, and in the other above the angleof the pubis as well as the distance fromthis point to the anterior superior spine, forthat will give the length of the curved partof the truss in front.

Operation for Strangulated Hernia.-Inthe operation for strangulated inguinal her-nia, you must carry the external incision inthe direction of the long axis of the tumour,commencing at about an inch above the open-ing at which the parts are protruded, andcarrying it down irt a straight line alongthe middle of the tumour towards the lowerpart of it ; it is not necessary, however, toextend the incision throughout its wholelength. That part where you principallywant room, is just where the parts havebeen protruded from the abdomen; there-

889

fore begin, at all events, at about an inchabove that, and then carry your incisiondownwards in the long axis of the tumourthrough the skin. With an ordinary pair offorceps and scalpel, you then carefully cutthrough the adipose substance which inter- Ivenes between the surface of the sac and

integuments. In the external inguinal ringyou have to cut through the skin, adi-

pose texture, and coverings, which are

often thin and separated into several laminse,composed of the cremaster muscle and tunicavaginalis of the chord. You.will cut throughthem cautiously, stratum by stratum, untilyou come to the sac, and when you are

approaching it, you will cut with every pos-sible degree of caution, for if you were to

cuttneautiously through the peritoneal co-vering, you might wound the intestine. As

you approach the sac, you lift up the differ-ent layers with a pair of forceps and cutthrough them, when thus elevated, with a iknife, carried nearly horizontally, and inthis way there is not much danger of wound-ing the protruded parts, the hernial sac

being separated from them by the fluideffused into it, so that when you cut throughthe peritoneal covering, a certain quantity offluid, generally of a reddish colour, escapes;sometimes there is a considerable quantityof this fluid, and usually it is enough toprevent all danger of this kind. When youhave thus cut into the sac, extend the open-ing upwards and downwards, so as to ex-pose the parts freely. It is not necessaryto cut through the integuments and the sacthe whole length of the hernia. I pointedout to you in the last lecture, that the com-ponent parts of the spermatic chord aresometimes separated in the case of hernia,and that sometimes either the vas deferens,or some other parts of the chord, passdirectly over the sac, so that if you were inevery instance to cut down to the very bot-tom of the tumour, you might endanger thechord, or the vas deferens. Such a com-

plete division of the tumour is not necessary;it you expose the sac for a space of two orthree inches, including the ring and thepart just below it, that will answer everypurpose. When you have completely ex-posed the contents of the sac, you introducethe finger and ascertain where the strictureis situated that confines the parts and pre-vents their return; your next object is tomake such a separation of that stricture asto allow of the replacement of the protrudedparts. There is some difficulty in accom-plishing this part of the operation. Unlessthe parts were very closely girt by the stric-ture, you would be able to return themwithout opening the sac, and of course theheruia would not then be strangulated. Youwould expect, therefore, where you cannotaccomplish this, to find a structure so com-

I plete, that you cannot introduce even the

extremity of your finger, therefore you mustdivide it by means of a cutting instrumentf conveyed in by means of a director; and asthe situation of the stricture is generallydeeper than the external wound you havemade, and perhaps higher up, you have gotto divide the stricture at the pai where youcannot see it, and where your proceedingmust be guided by your anatomical know-ledge. ltecollect that intestine, perhapsomentum, are contained within this stric-ture, and that there may be only just suffi-cient room for the passage of the director,and that you have got to introduce a cuttinginstrument on that director ; take care,therefote, that you do not wound the partswhere it is thus introduced. In doing thispart of the operation, you must be sensiblethat a considerable danger exists, and thata good deal of care is necessary, even al-

though you have operated repeatedly, inorder to enable you to avoid it. I thinkthat a person will hardly find, even aflerlong experience, that he can perform thispart of the operation, without feeling it ne-cessary to adopt all possible precaution toprevent the intestine being wounded, thepart to be operated on embracing the pro-truded viscera very closely, and being com-pletely out of sight. You introduce thena director under the stricture, and, in orderto avoid as much as possible the danger Ihave mentioned, you will find it expedientto employ a director with a deeper groovethan that which you ordinarily find in a

dressing-case of instruments ; a steel di-

rector, with a very deep groove, is to be

passed in ; it passes easily into the stricture,and the depth of the groove conceals theblade of the knife which you employ, so

that there is very little risk of wounding theparts if you operate cautiously : at the sametime you must employ the fore-finger of yourleft hand, or the finger of an assistant, who,with his finger or the handle of a scalpel,presses the intestine out of the way of theknife when you are executing this part ofthe operation ; and this, I think, you willfind the best way of proceeding. A parti-cular kind of curved knife has been recom-mended by Sir Astley Cooper for perform-ing this part of the operation. Of course

you are aware, that under circumstanceswhere you have not got a proper instrumentto divide the stricture in incarcerated her-nia, you must divide it with the common

bistoury, which you have curved, but thisinstrument, which I now show you, is cal-culated to perform what you want more

safely; it appears like all ordinary curvedknife, but it is blunt for half an inch at thepoint; then there is a cutting edge forabout three-quarters of an inch, and the restis blunt. You carry this knife into the part

890

flat, then you turn up the cutting edge againstthe stricture, and cautiously divide the con-stricted part. This is an instrument that

may be conveniently employed in that partof the operation.

It is not necessary to make an extensivedivision in strangulated hernia ; all you wantis such an opening as will allow you to re-place in the abdomen the parts that havebeen protruded and confined by the stric-ture. A division, perhaps of a quarter ofan inch, will enable you to accomplish thepurpose, and if it will, it is not necessary todivide more than that. The further youdivide the parts in the operation, the morethey are loosened, and the greater probabi-lity is there of a return of the hernia afterthe operation, and of its acquiring a con-siderable magnitude; by limiting the divi-sion, just to the extent absolutely necessary,you avoid that risk. You will, therefore,introduce the knife, keeping the edge of itclosely applied against the part that con-stitutes the stricture, and cautiously dividea little of that part. When you have made Ia small division, attempt to return the parts,and if you find that the opening is not ade-quate to their return, you must repeat theincision, making the division a little larger.

In the case of inguinal hernia, you mayfind the stricture either in the tendon of theexternal oblique, or it may be formed at thesuperior and internal abdominal ring, bythe lower edge of the internal oblique andtransversalis ; or by the neck of the sac,altered in the way that 1 have already de-scribed. If it is formed in the two ways Ihave last mentioned, either by the edge ofthe obliquus internus and transversalis, orby the altered neck of the sac, you may findthat it will be situated considerably withinthe parts you have divided, and that youhave to introduce your finger and divide itat a considerable depth.The only other point of consequence to

attend to, in the case of inguinal hernia, isthe direction to be given to the instrumentin performing this part of the operation.And here you must recollect the distinctionI have made between the two kinds of rup-ture ; in the more common species, the epi-gastric artery will be situated on the inside,while, in the less frequent kind, it is situ-ated on the outside of the neck of thehernial sac. In the case of external inguinalhernia, you might safely divide the stric-ture upwards and outwards-=-that is, to-

wards the anterior superior spine of theilium; but, in the other species, if youwere to divide the stricture in that direction,you would run a great risk of wounding theartery; if you were to divide it upwardsand inwards-that is, towards the lineaalba, in the ordinary kind of inguinal hernia,then also would you endanger the artery.

In order then to avoid all risk of this occur.rence, you should divide the stricture di-

rectlv upwards&mdash;that is, in a line parallel tothe linea alba ; and the artery will then beperfectly safe, whatever kind of inguinalhernia you maybe operating upon; you areto cut not upwards and outwards, nor up-wards and inwards, but divide the stricturein the middle, in a direction parallel to thelinea alba-that is, straight upwards, andthen there is no danger, in either kind nfinguinal hernia, so far as the artery is con-cerned.

Having then divided the stricture, youmake a gradual pressure on the protrudedparts, and you find that they re-enter imme-diately the cavity of the abdomen; the in.testine passes into the abdomen with the

greatest facility, and you can easily returnthe omentum also, when that is protruded.Sometimes you find the intestine very

much discoloured. You find it of a deeplivid red-a dark-brownish red, of a deepebocolate-brown colour; or of a livid tint

I hardly distinguishable from black, and allthese discolotations may exist, without anyserious change in the state of the coats ofthe intestine, that is, withoutloss of vitalityin them. (Jndfr such circumstances, theperitoneal covering retains its ordinarypale appearance ; and if the vessels are fullof blood, by making a gentle pressure onthem, in the direction of the venous circula-tion, you can squeeze on the blood, and thevessels will again become full, showing thatthe vitality still exists. If the pattsshould have become mortified, they assumea dirty brownish hue, and the peritonealcovering has lost its pale colour; and thereis generally this distinction between mor-tified parts and those that are not mortified,that in the former case, if you squeeze theblood out of the vessels, when they do notfill again, so as to show that the circulationgoes on; and usually when this seriouschange has taken place, there is more orless of that disagreeable fetid smell, whichcommences when mortification has super-vened. A portion of intestine simply changedin colour, however considerable that changemay be, may be safely returned into the ab.domen ; but if it has actually lost its vitality,it would be very improper to replace it

eventually, because it would become sepa.rated, the contents of the alimentary canalwould escape into the abdomen, and thepatient would lose his life. If the intestinehas lost its vitality, you may make a freeincision through it : by so doing, you allowthe alimentary canal to unload itself; youlet out the f&aelig;ces and flatus which fill itabove the stricture, and thus you give greatrelief to the patient. With respect to the

omeRtum, if that is in its natural state-if itpossesses its natural redness and softness of

891

texture, you mav replace it in the abdomen.Frequently, however, the omentum has be.come considerably thickened and indurated.-formed into an unnatural mass which youcannot easily unfold, so as to make it exhibitits natural state, the neck being especiallycondensed and formed into a pretty firmthick ring. If a piece of omentum in thisstate were returned into the abdomen, youwould find it become a source of irritation,you would find the parts inflamed, that

suppuration would be produced in the ab-domen, and that the returned omentumwould thus become the cause of great dangerto the patient. To avoid this, after return-

ing the intestine, you must cut off the pieceof omentum that is thus situated ; and hav-ing done so, take up the vessels one by one,and tie with small ligatures any that youmay observe to bleed. Sometimes theomentum has been left in the sac : undersuch circumstances it will separate occasion-ally, after the performance of the operation;or the part that has been thus left, willbecome covered with granulations, and forma portion of the cicatrix. 1 think it best,however, if it is particularly altered, eitherby long continuance in the hernia, or by thechange occasioned by the strangulation, tocut it off, and take up on the cut edge the

I bleeding vessels which you may find trouble-some.

Having thus disposed of the parts con-tained in the hernia, you bring together thesides of the wound in the usual way, and

you generally find it better to unite them bysutures. The situation of the wound is notconvenient for union by adhesion ; the edgescan be brought carefully together and unitedby sutures. Then the most advantageousdressing is, soft cloths dipped in coldwater; or perhaps immediately over thewound, you may lay a rag spread withsimple cerate. In some instances parti-cularly, if the parts protruded were large,there may be such a tendency in them toescape again, that you require some pres-sure to be made in the situation of the ab-dominal ring ; in this case, after uniting thewound by sutures, you may employ com-presses of rag over the ring, and produceas much pressure there as may be foundnecessary to prevent a return of the hernia;it is expedient also to direct the patient,whenever he moves in bad, or has occasionto use the bed-pan, to put his hand over thepart and make slight pressure, for the pur-pose of preventing any protrusion undersuch exertion.

I have spoken to you of the course thatshould be adopted, in cases where you find ithe intestine not mortified ; the same coursemav be adopted if the changes in the hernia,visible externally, previous to the operationare such, as to lead you to expect that morti.

fication has occurred. If the integumentshave become red externally, if the violent

symptoms have subsided, and the pulse hasbecome small, feeble, and intermittent, andat the same time the patient is covered witha clammy sweat, you may expect to findthat the parts protruded have undergonemortification, though, on the other hand,this change may have taken place wherethese symptoms have not exhibited them-selves before the operation. The parts maybe mortified,’although there be no appearanceof it externally, and although there may beno particular alteration in the pulse ; but itis always a very formidable sign when yousee a redness, and more particularly, a lividstate of the integuments. As long as theprotruded viscera remain in their naturalstate you never have the integuments in-

flamed, and, therefore, when you see theparts covering the hernia thus discoloured,you may be sure that not only are the pro-truded parts pretty considerably inflamed,but that they have undergone mortification.Under such circumstances, you may deem itnecessary to make an opening, and, perhaps,give the patien t that relief that a free divisionof the mortified parts will afford ; that isall you can do in such a state of danger.Now, in many cases it is found that the

mortified part of the intestine separates, andI that the contents of the alimentary canal arefreely discharged through the opening thatis made either in this way or by the surgeon.After a time the discharge of’ the faecesthrough the wound diminishes, and the pa-tient has faeeal discharge in the natural way ;and in certain instances the dischargethrough the .wound ceases entirely, thecontents of the alimentary canal take theirnatural course, the wound closes up and

complete recovery ensues. In other in-

stances the patient recovers his strength, butthe wound does not close ; the contents ofthe bowels are permanently dischargedthrough the wound, and, in fact, the casethen becomes, what is technically called,

Artificial 4nus,-a case in which thefaecal matter is discharged at the groin, orany other situation where the hernia hasexisted. This, of course, is a state ex-

tremely annoying to the individual, andwhich it would be very desirable to re-move. In some instances an operation hasbeen performed which has had the effect ofrelieving the patient from this disgustinginfirmity, by producing a closure of the un-natural opening, and procuring a course forthe f&aelig;culent matter in the natural direction.At first sight it would seem rather difficultto understand how the natural passage of thecontents of the bowels could be restoredafter a portion of intestine had mortified ; ibut by examining the circumstances attend-ing cases in which this has taken place, the

892

process which nature adopts becomes toler-rably obvious. If a portion only of the dia-meter of the intestine is included in the stric-ture, we find that part of the mesentery cor-responding to the portion included in thestricture, to be drawn down towards the

inguinal canal ; and if a third of the diame-ter of the intestine is included in the stric-ture, the passage of the alimentary matter iscompletely impeded because the internaland muscular coats form a permanent fold onthe inside of the intestine, opposite the partwhere the mesentery is drawn down. [Thelecturer exhibited by a diagra2n the man-ner in which, accor-ding to his statement, anartificial anus is formed, and the obstructionoccurs.]Now, in certain cases, the course we find

to take place is this,--the inflammation thathas proceeded to such an extent a3 to pro-duce mortification, produces also adhesionbetween the sides of the sac and the partsin its immediate vicinity; which thus be-come adherent to it, after the stricture hasbeen relieved, and the bowels have been

emptied ; the mesentery and portion of theintestine are gradually drawn back into theabdomen, and thus a portion of the sac re-

mains adherent to the bowel, supplying’ theplace of the part which has been lost;[explained again by diagram;] and in thismanner the integrity of the alimentary canal isre-establisbed.The contents of the bowels coming down

in the direction chalked out in this diagram,are prevented from going into the lower partby the prominence which you here see, butthey pass into this part of the sac, and thusthe course of the alimentary contents isre-established, where the radical cure hastaken place. ’This circumstance is pointed out by Scar-

pa ; who observing the portion of the her-nial sac that is drawn in by the gradual re-tirement or recession of the intestine, to

have a funnel-like shape, calls this the ment-branous funnel-shaped cavity, and pointsout how the alimentary substances comingdown through this membranous funnel-

shaped cavity, pass on into the lower part ofthe intestinal canal.There are some instances, however, in

which the two portions of the bowel becomesituated very nearly parallel to each other,and where this process of repair cannot takeplace. Now I would suppose the protrudedportion of the intestine to be representedby those two lines, &c. [Referring againto a diagram to show the parallel situationof the two ends of the divided intestine.]Here the alimentary contents must come

out of the opening ; therefore, in such acase, the discharge of them through theartificial anus must be permanent. But atthe same time, if you could unite those two o

portions of bowel for a certain space fromthis opening within the cavity of the ab.domen-if you could make them adhere to-

gether for the space of a couple of incliesabove the wound, you would then have adirect opening from the one to the other;that is, if you could remove a certain portionof the septum that separates the two, youwould then have the contents coming downfrom the upper portion to the lower; andthe same process would take place wherethe ends of the bowel, instead of being par-allel, were united by a very acute angle-ifyou could destroy the portion that formsthe septum between the two, then the con.tents would go from the superior to theinferior palt. Now this object has beenaccomplished by a very ingenious operation,devised and practised in a great many casesby Baron Dupuytren, and I think that it doesgreat credit to theingenuity of the inventor.In the first place, he ascertained by exam.ination, that the cause which prevented thepassage of the contents of the bowels, fromthe superior to the inferior part of thecanal, consisted in the projection of the coatsof the bowel between the two openings, andhe considered what process could be em-ployed to destroy that projecting part. Hethen hit upon employing a kind of forcepswhich admit of being’ opened at both ends;one end is introduced above the dividedbowel and one below; and then a certainportion of the coats of the upper and lowerends where they lie in close contact (whenthe ends are lying parallel, or of the project-ing part when they are united at an acute

angle) is embraced between the two endsof the forceps, which are so constructed, asto produce a pressure upon the parts em-braced, which will destroy their vitality.When the surrounding parts have been in.flamed and have suppurated in the ordinaryway, the portion thus pressed becomesloose and separates, and a free communica.tion is established between the upper andlower ends of the bowel. Now I shall justchalk this process out to you on the board.[The lecturer here made a diagram of tlaeparts.] Now, that is the operation whichhas been performed for the removal of anartificial anus by Baron Dupuytren in manyinstances. I have not had an opportunitvof trying it myself, for to say the truth, Ido not find those cases of artificial anus tobe very numerous, and all cases in whichthey exist, do not admit of its performance.It is necessary that the two portions ofbowel should either be united at a very acuteangle or lie parallel to each other, in orderto allow of the performance of this opera-tion, and I have not met with a case inwhich the parts were thus situated. Iwould therefore beg to recommend you, if

you have a case of this kind to operate on,

893

to consult the account Baron Dupuytrenhas lately published of this operation, in aeew French Medical Dictionary, (Dic-tionnaire de Medicine et Chirxurgie,) in thethird volume of which, is the article towhich I beg to refer you.

Prolapsus of the Intestine from Artifi-cial Anus.&mdash;In the case of artificial anus,where there is a regular discharge of thecontents of the alimentary canal through theopening, it sometimes happens that the in-testine prolapsus at that opening, the samekind of prolapsus takes place that may occurat the natural anus, and which constitutesprolapsus ani. It is everted in the samemanner as the finger of a glove may be; and I

you may have a large portion of it descend-mg to the extent even of some inches. Youmay have a double prolapsus ; one at thesuperior and one at the inferior edge of theintestine. Such a protrusion may be easilyreturned, but it is difficult to keep it re-placed.- Stercoral Fistula.&mdash;After an opening ofthis kind has been closed, or at least afterit has been so far closed that the contentsof the bowels pass in their natural channel,it sometimes happens thata minute openingremains, through which there is occasionaldischarge of a little yellow fetid flnid thathas been called f&aelig;cal&mdash;a faecal fistula, whichhas sometimes been found extremely diffi-cult to heal.

Inguinal Hernia in the Female.&mdash;Ingui-nal hernia in the female is essentially thesame affection, and the operation for it isthe same as in the male ; 1 have, therefore,nothing particular to add to what I have al-ready said. In considering the operation asperformed in the female, however, for in-

guinal hernia, where the intestine descendsthrough the upper or internal opening ofthe canal, and is strangulated there, withoutpassing through the external ring, it is sofar peculiar, that if you were to operatethere, you would have merely to make an

opening through the external oblique mus-cle ; as to the rest, it is the same as in theother case.Hernia Congenita.-Tlere is a case in

which the protruded parts are found in con.tact with the testicle, and this is calledhernia congenita. It takes place thus: thecommunication between the tunica vaginalisand cavity of the abdomen, which exists im -mediatelv after the testicle has descendedinto the scrotum, which does not becomeclosed in such cases, but remains perma-nently open ; in these instances the tunicavaainalis is, in fact, a kind of process or con -tinuation of the cavity of the abdomen. Andin individuals in whom this process of pe-ritoneum, leading from the inguinal canaldown to the testis, has not become closed,if hernia takes place the parts will pass

through that opening, and come to the testi-cle. The term hernia congenita would leadyou to suppose that it existed at birtlt,which, however, is not the fact; the herniadoes not take place till some time afterbirth, perhaps not till the patient is someyears of age ; but the state of parts whichproduces it exists at birth, although the

hernia itself does not then take place.When you come to lay open the sac, youfind that the parts lie in contact with thetesticle; and, of course, previously to the

operation, you do not find the testicle situ-ated free and below the protruded parts, asin the case of ordinary inguinal hernia.Here is a specimen of a case of this kind;here is the sac laid open, and you observethe testicle projecting into the lower partof it.

The remark which I have made to yourespecting the distinction between hernia

congenita and common inguinal hernia, inrespect to your not being able to feel thetestis separate from the rupture, reminds methat I did not, in the commencement of thelecture (as I should have done), mention toyou the particular.

Symptoms and Diagnosis of InguinalHernia.&mdash;I began by speaking of the opera-tion, without having mentioned what thesymptoms are by which you are best able todistinguish inguinal hernia from other affec-tions which take place about the same parts.When a tumour exists in the anterior partof the inguinal region, or when you see atumour in the scrotum which has previouslyexisted in the groin, and descended into thescrotum ; when you find, on examining thattumour, that you trace it up to the ring, andthat it passes into the ring; when you findthat the testis is situated below it, and

quite free, and that the spermatic chord issituated along the middle of its posteriorpart, and can also be pretty freely felt;when you find in such a tumour, that thecircumstances exist which I have mention-ed as the general symptoms of hernia-namely, that the tumour disappears underpressure, or when the patient is in the hori-zontal position, and reappears when he is inthe erect position, or when the pressure isremoved&mdash;that it increases on coughing, orwhen the individual holds his breath, thenyou may be satished that the case is one ofinguinal hernia, or bubonocele.

There are, however, various other com-plaints attended with swelling, occurring inthe same situation, from which it is neces-sary you should be able to distinguish thetumour formed by an inguinal hernia, andin certain instances the distinction is by nomeans easy. li) the first place, there is hy-drocele, the tumour formed by which is,however, generally very different from thatof inguinal rupture ; there is hardly any

894

probability of confounding the two. -tlydro-cele commences from below and ascends-arupture commences above and descends.The surface of a hydrocele is smooth anduniform; the sense of fluctuation, the ob-vious existence of a fluid, as evidenced bythe touch, form an almost complete distinc-tion between the two. The tumour of hy-drocele terminates above, and is bounded atthe upper part of the testicle, while thetumour of hernia is not so bounded, but iscontinued into the abdominal ring. Thereare some instances, however, in which thetumour of hydrocele ascends along the frontof the spermatic chord, and even passes intothe ring, so that the mere limit of the tumourabove is not a sufficient distinction ; and,indeed, you will often find it advantageousto do what I recommended to you before-namely, examine the tumour with a candle,when the transparency of the fluid will beimmediately perceptible, if it be hydrocele.Varicocele is a swelling of the spermaticchord, which mav be confounded with hernia.The tumour of varicocele is made up by theenlargement of a congeries of vessels, or dis-tended and enlarged veins, but the feelingof this to the fingers when it exists is so

peculiar, that it hardly admits of being con-founded with hernia. There is, however,this confusion between the two, that a vari-cocele like a hernia recedes in a great mea-sure when the patient lies down, becausethe veins then become empty, and the tu-mour returns when the patient is erect;but, on the one hand, the tumour will notreturn on coughing, so long as the patientis recumbent ; and, on the other, it will bereproduced when he stands up, even thoughthe abdominal ring be closed with the

fingers; the difference, however, of feelingbetween the two is sufficient to enable youto distinguish them. You should also beaware of the irregularities that take place inthe descent of the testicles. The tumourthus produced might be mistaken for ahernia,because it is sometimes attended with pain; ;’you should therefore examine the scrotum

carefully, in order to ascertain whether bothtestes have descended or not. An encystedtumour of the spermatic chord might be con-founded with hernia ; it is however veryrar.’, and is so distinct that it hardly admitsof being confounded with a hernial tumour.

VACCINATION.

IT is stated in the Journal Universel,that Dr. Barres, Jr. of Bordeaux, vaccinateda child three years of age, making four

punctures, from which no effects resulteduntil about two mouths afterwards, whentwo genuine vaccine pustules were develop-ed, from which other children were success-fully vaccinated.

RUPTURE OF THE SPLEEN INTO FRAGMENTS,WITH EFFUSION OF BLOOD INTO THE PE-

RITONEAL SAC, THE RESULT OF HARD

DRINKING.

By ALEX. THOMSON, M.B.

Circumstances relating to the last illness butonc, as 1’elated by Mr. Vjc!:EKs, Sur-geon, of 9, Thayer Street, ManchesterSquare.

" GEORGE GOLDING, aged 39, by trade a

farrier, first applied to me on Friday, 26thof February, labouring under the followingsymptoms: pain and tightness across thechest, accompanied with dyspn&oelig;a; skin

hot, tongue moist, and pulse exceeding 100,and very hard.

I ordered 20 f. of blood to be taken froma large orifice in the arm, and gave an activeaperient consisting of calomel and salts.

Evening. The symptoms were increased.VS. ad f. xvj. Mist. cathartica et antim.tartariz. secundis horis.Feb. 27. To-day the pain is returned;

increased dyspnoea; pulse 120; bowels

freely evacuated. VS. ad f. xx. Repet.medicamenta.

Evening. The symptoms mitigated, theskin cool, the pulse softer and less frequent,with profuse perspirations.

28. To-day the cough is very trouble-some, but the general symptoms amelio-rated. Ordered emp. vesicat. pectori, andto take a mixture of salts, syr: scill&aelig; andinf. ros., and pulv. Doveri gr. x. h. s.

, March 1. Better; continue medicine.I 2. Has a return of difficulty of breathing,unattended with pain ; pulse quick.

R Potass&oelig; nit., jss;Magnes. sulph., iij;Digital. tine., 5jVini ipecac., ij;Aqu&oelig;, vj;De quo sumat., j 4tis horis. Rep.

pnlv. ipecac. c, hor. som, s.3. Cough incessant, with tightness across

the chest; pulse 100, full, and hard. VS.ad Ibj. Ordered a pill, with ext. papav.pil. scill&aelig; c. . gr. ij, ant. tart. gr. , to befrequently taken. Continue medicine. Ca-

thart., with ant. tart. ut antea.’ 4. Bowels freely opened; the tightnessand breathing relieved; pulse better. Con.tinue medicine.

Omittat nzag. sulpli., ss in mistura.5. Better. Rep. med. 6tis horis.9. I observed, for the four or five pre-

ceding days, a disposition to sit up in bed.On asking him the reason, he said be felt agreat uneasiness and difficulty of breathing,which was always relieved on sitting up.Cough still diHicult, with abundant expecto-ration. Ordered the pills as before, With