contraction of the abdominal muscles, and particularly of the diaphragm; and, as the contraction of these muscles must always diminish the abdominal cavity, these causes therefore are frequently productive of hernia. 2. Falls, in consequence of the derangement they produce in the abdomi nal viscera, from the sudden and violent shock with which they are often attended, are often the immediate causes of hernia. 3. Persons of a preternatural laxity of frame are very liable to hernia. The containing parts of the abdomen, from the want of a sufficient tone and firmness, are unable in such people to resist on all occasions the weight of the different viscera; and they are therefore more particularly exposed to disorders of this kind on the slightest application of any of the causes already mentioned.

In whatever situation a protrusion of any portion of the intestines occurs, except in the hernia congenita, as all the viscera are contained within the peritoneum, a portion of that membrane, it is evident, must be carried down together with the parts protruded; and, in every such instance, it is this portion of the peritoneum which goes down along with the gut that is termed the hernial sac. The size of this sac is various in different subjects, and in different stages of the same disorder. On the first appearance of the disease it is commonly of no very considerable size, as such swellings seldom acquire any great bulk at once; but, by repeated descents of the bowels, it comes to be pushed lower and lower, till in some instances its bulk becomes very considerable indeed; and when, in this advanced period of the disorder, the sac happens to be laid open, it is found to contain either large quantities of omentum or intestine, and frequently large portions of each. As the peritoneum has this property, in common with many other parts of the body, of thickening according to the degree of any gradual extension applied to it, so in many instances the thickness and firmness of the hernial sac are often very enormous.

All the bad symptoms which are found to occur in herniæ, proceed, as may be readily supposed, either from obstruction to the passage of the faces when the intestinal canal forms the tumor, or from a stoppage of circulation occasioned by stricture on the prolapsed parts; so that the attending symptoms, it is evident, will be always more or less hazardous according to the nature of the parts so protruded. Thus, when the omentum alone forms the substance of hernial swellings, as that organ does not appear to be so immediately necessary as many of the other viscera, such tumors are not so frequently productive of bad consequences; at least they are seldom in any degree so hazardous as when a part of the alimentary canal is either protruded by itself or along with the omentum.

Although this, however, is in general the case, yet it sometimes happens, that even an omental rupture is productive of no small degree of danger. When a stricture so complete upon it occurs as to occasion a stoppage of circulation in the protruded part, mortification with all its bad consequences must be the certain event: and the connexion between the omentum, stomach, and other viscera, is such, that a sudden VOL. XI.

descent of any considerable portion of the former, sometimes brings on vomiting, hickup, and other troublesome symptoms; and, lastly, though a rupture containing omentum only might not of itself produce any thing bad; yet, as the passage through which the omentum has slipped must of necessity continue open so long as that viscus remains protruded, and as that circumstance alone must, so long as it continues, render it more easy for a portion of intestine likewise to get down, this of itself is a sufficient reason for entitling even this species of hernia to the serious attention of practitioners.

But whatever the contents of such swellings may be, as their remaining in some instances for a considerable length of time without being productive of any bad symptoms must proceed entirely from the circulation continuing to go freely on, notwithstanding the derangement of parts; so, whenever a stricture occurs up the protruded viscera, sufficient to produce either a stoppage of the circulation or of the fæcal contents of the alimentary canal, when a portion of intestine forms the disease, the following in general are the symptoms which accrue :

An elastic colorless swelling is observed at the part affected; a slight pain is felt, not only in the swelling itself, but, if part of the alimentary canal is down, a universal uneasiness is perceived over the whole abdomen; and this pain is always rendered worse by coughing, sneezing, or any violent exertion. The patient complains of nausea; frequent retching; can get no discharge by stool; becomes hot and restless; and the pulse is commonly quick and hard. When the swelling is formed entirely by a portion of intestine, if no fæces be contained in it, it has a smooth, equal surface, and is easily compressible, but instantly returns to its former size on its pressure being removed; but, in ruptures of long standing, where hard faces have collected in the protruded bowels, considerable inequalities are detected. When again the tumor is composed both of intestine and omentum, its appearance is always unequal, it feels soft and somewhat like dough, and of course is not so elastic as when part of the intestinal tube only is down; for although, like the other, it is compressible, it does not so readily regain its former dimensions on the pressure being taken off.

These symptoms can never happen from the presence of omentum only; for although stricture produced on a portion of omentum, even when no part of the intestinal tube is down, does now and then occasion a good deal of distress, such as pain in the part, sickness, vomiting, and twitching pains through the whole belly; yet no obstruction ever occurs from this, and of course none of the symptoms ever prove so alarming as when any part of the gut is affected. If these symptoms we have described, as being produced by a strangulated bowel, are not now obviated by a removal of the stricture which produced them, the nausea and retching terminate in frequent vomitings, first of a bilious, and afterwards of a more fetid matter; the belly becomes tense; the pain turns more violent; a distressive convulsive hickup comes on; the fever, which before was not apparently of much consequence,

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now becomes very formidable; and a total want of rest, with a very disagreeable state of anxiety, continues through the whole course of the complaint. These symptoms having gone on with violence for some time, the patient is at last commonly relieved in a sudden from all manner of pain; and then he flatters himself that all danger is over. But instead of that, the pulse, from having been hard and frequent, becomes languid and interrupted; cold sweats break out over the whole body; but especially on the extremities; the eyes acquire a kind of languor; the tenseness of the abdomen subsides, and the swelling of the part affected disappears; the teguments covering the parts, which before were either of a natural appearance or had somewhat of a reddish inflamed cast, now acquire a livid hue, and a windy crepitous feel is distinguishable all over the course of the swelling. If the protruded parts have not of themselves gone entirely up, their return is now in general easily effected by a small degree of pressure, and the patient then discharges freely by stool; but the cold sweats increasing, the hickup turns more violent, and death itself is at last ushered in by its usual forerunners, subsultus tendinum, and other convulsive twitchings.

These are the ordinary symptoms of what is termed a strangulated or incarcerated gut-hernia; that is, when the parts protruded become so affected by stricture as to produce pain; and do not either return to their natural situations on the patient's getting into a horizontal posture, or cannot even be immediately replaced by the hands of a practitioner. In whatever situation a strangulated hernia occurs, the only rational method of cure, it is evident, must consist in the removal of that stricture which prevents the return of the protruded parts. It is that stricture which ought to be considered as the cause of all the mischief; and, unless it be removed, nothing effectual can be done for the relief of the pa

tient.

As soon as the assistance of a practitioner is desired for the removal of symptoms in cases of hernia, the first circumstance requiring his attention is the placing of his patient in such a posture as will most probably favor the return of the protruded parts. Placing the patient's feet over the shoulders of another person, while his body is allowed to hang downwards, has on some occasions answered when other means have failed. The surgeon should at the same time endeavour to assist the return of the bowels, by means of gentle pressure with his hands and fingers. In the inguinal or scrotal hernia, this pressure should be made obliquely upwards and outwards, to correspond with the opening in the external oblique muscle; in the femoral hernia it ought to be made directly upwards; in the umbilical and ventral hernia, directly backwards.-The swelling should be grasped with one hand at the bottom, while with the fingers of the other hand an attempt is made to push gently the contents of the tumor into their place, always observing that the parts last protruded be first reduced. This operation is by authors termed the

taxis.

When the means now mentioned have failed,

no remedy affords more relief than blood-letting. The quantity to be drawn ought chiefly to be determined by the strength of the patient. There is scarcely any disease, however, where such large quantities of blood can with propriety be taken from weak people. Bleeding, till the patient is in a state of deliquium animi, is frequently known to produce a more effectual relaxation of the muscles than can be done by any other means. On that account it is sometimes advised in cases of hernia, and the practice is now and then attended with advantage.

If, however, all these endeavours prove ineffectual; if the swelling is not reduced, but still presents an inflamed tense surface; if the fever still continues and even becomes worse, the operation of dividing the parts producing the stricture can alone save the life of the patient. To determine the exact time at which to proceed to an operation has been considered as one of the nicest points in surgery. In general, when every attempt has failed, and no repetition of the former remedies is likely to succeed, the surgeon ought certainly to proceed to the operation. A few hours, even when assistance has been early applied, is perhaps all the time which ought ever to be consumed in trials of this nature. But however necessary this operation may be when a patient's life is in danger, as it is always attended with some degree of hazard, it ought never to be practised where symptoms of strangulation do not exist.

In that kind of hernia called chronic, the circulation of the part forming the hernia, as well as the peristaltic motion of such parts of the alimentary canal as have been protruded, go freely and regularly on. There are many instances of large hernia falling down even to the bottom of the scrotum, and continuing there for many years, without producing any interruption to the usual discharge by stool. All that can be done here is to prevent any accumulation of fæces in the intestine, by prescribing a proper diet, and the occasional use of gentle laxatives; and obviating any inconvenience which might arise from the weight of the tumor, by the application of a proper truss or suspensory bandage; to warn them of the risk to which they are constantly liable, and to caution them against violent exercise, particularly leaping, and every sudden exertion. The truss ought to be fitted exactly to the part for which it is intended; for, without the utmost nicety in this respect, it must always do more harm than good: for the sole purpose of a bandage, in cases of hernia, is to prevent effectually the falling down of such parts as have been newly replaced. If therefore the pad or bolster of the bandage does not bear properly against the opening upon which it is placed, a portion of gut may slip out, and be materially injured by the pressure of the pad.

The circumstances to be attended to in performing the operation for hernia, in general, are these. A table of convenient size and height being placed in a proper light, the patient must be so laid on it as to relax the diseased parts as much as possible, and then secured by proper assistance. To lessen the contents of the abdomen as much as possible, the bladder ought to be

emptied previous to the operation. An incision is to be made with a common round-edged scalpel through the skin and part of the cellular substance, long enough to allow the stricture to be fully exposed. The rest of the cellular substance is then to be divided with the greatest attention. That part of the muscle forming the stricture or ring must next be laid distinctly in view. A small portion of the protruding sac must also be exposed: after which the directory is to be passed between the ring and the sac. A straight probe-pointed scalpel is now to be introduced into the groove of the directory, and by it the ring is to be dilated till the point of the finger can be introduced. The finger is here considered as the safest director; for, it being insinuated into the aperture in the tendon immediately above the protruded parts, the point of the knife is easily introduced upon it; and, by keeping the end of the finger always a little before the knife, the opening may be enlarged to any necessary extent without risk of wounding any of the contiguous parts.

By the ease with which the finger is introduced, the operator will be enabled to judge when the ring is sufficiently dilated; and, if the strangulation was entirely in the ring, it will now be evident that every obstacle to the reduction must be removed, and of consequence that the prolapsed parts may be returned with little difficulty. If the patient be young, or if the disease has continued a considerable time, such a degree of inflammation frequently ensues in the neck of the sac as to produce thickening and straitness; so that, after the sac and its contents have been entirely freed from the stricture of the ring, the intestines cannot be reduced. We judge this to be the case when, after the stricture of the ring has been removed, the parts prolapsed do not expand into their natural size, and farther, when they make resistance when we attempt to return them. In this case the neck of the sac must be opened with the utmost caution, to avoid wounding the parts within it.

If the herniary sac, under the straitened place of its neck, be thin and transparent, and there is little or no reason to suspect an adhesion of the bowels to the sac, the best method, as Dr. Monro, in his publication on the Bursa Mucosa, observes, will be to make a small hole in the sac below the stricture, and then to introduce a small furrowed probe, and to cut cautiously upon it. But if the sac be thick and dark colored; and there is likewise a suspicion that the bowels may adhere to it, the easiest and safest manner will be to make the hole in the peritonæum above the stricture; then to introduce a common probe, bent near its point into a semicircle, with its point directed downwards through the strictures, into the sac; and upon the point of it to make, with great caution, another small hole; after which we may either cut upon the probe, or introduce a furrowed probe, and divide the neck of the sac.

After this, the bowels are to be returned by pressure upon the sac, without opening it farther; and the sides of the wound in the skin are to be brought together, and kept so by means of slips of adhesive plaster, though stitches made at the

distance of a finger's breadth from each other will exclude the air, and prevent the return of the bowels more effectually. Over these are to be laid several folds of charpie, and the whole is to be secured by a bandage adapted to the nature of the part.

When the hernia is of long standing, and when there is reason to think adhesions have taken place between the sac and bowels, or that mortification has already begun, or that some filaments run across the sac and prevent the reduction, or that there is water in the sac, or that the gut is in danger of being entangled from a part of the omentum being down, a different method of operating becomes necessary.

The patient is to be placed as already directed. The operator is to grasp the tumor with the one hand, so as to make the skin tense on the fore part of it, while with the scalpel in the other he divides the skin from one end of the tumor to the other. The cellular substance is by gentle strokes to be divided, till not only the ring, but the whole length of the sac, is laid bare. An opening is now, in the most cautious manner, to be made into the sac by slight scratches, to avoid hurting any of its contents. In making this perforation, which is considered as the nicest part of the operation, considerable assistance is obtained from the use of the small directory, upon the point of which the fibres of the sac are to be successively raised and divided till an opening is made. The opening is to be enlarged till it admit the fore finger of the left hand, which serves as a directory for conducting the straight probe-pointed scalpel with which the sac is to be divided through its whole length. The sac being laid fully open, the parts contained in it ought to be examined with the nicest attention, to discover whether they are all sound or not; and if, upon any attentive inspection, it is found that they are not evidently in a gangrenous state, even although they seem considerably inflamed, they should be immediately returned into the abdomen. When adhesions take place between different parts of the protruded gut, the greatest caution is necessary in separating them. When the bowels cannot be reduced with ease, the ring is to be dilated by the blunt-pointed scalpel in the manner already directed. But in case gangrene or mortification is already begun all these parts must be cut away, as the return of such into the cavity of the abdomen must be generally attended with the worst consequences. We now come to notice. THE HERNIA INGUINALIS OR BUBONOCELE.

This species of hernia is formed by a protrusion of some of the abdominal bowels through the rings of the external oblique muscles. It is known by the general symptoms of hernia already enumerated, and by a soft and somewhat elastic swelling, beginning in the groin, and cescending by degrees into the scrotum in men, and into the labia pudendi in women. Wher. the hernia contains omentum only, the swelling is both more soft, compressible, and more unequal than when the gut alone is down; the scrotum becomes more oblong than in the intestinal hernia; and, when the quantity of omentum

is large, it is also much more weighty than a gut rupture of the same size; but frequently the tumor is composed of both gut and omentum, and then the distinguishing symptoms of each can never be so clearly marked.

Bubonocele may be confounded with certain other diseases; but may be distinguished by the following marks which are present in these disorders, while the symptoms of hernia are absent: from venereal bubo, by the presence of that incompressible hardness with which all such swellings are at first attended, and by the fluidity of matter which in the suppurative state is always observable: from hernia humeralis, or swelling of the testes, by the absence of the hardened and enlarged state of the testis and epidydimus, and likewise of the pain, the tumor of the testicle being remarkably heavy in proportion to the bulk, the spermatic process being commonly free from the swelling. In the hernia humeralis, also, the intestines are unobstructed, and the general symptoms of hernia are wanting. From the hydrocele of the tunica vaginalis testis, by the tumor generally feeling more smooth to the touch than in hernia, by the swelling here beginning in the under part of the scrotum and ascending, by the spermatic cord being always free and distinct, and by a fluctuation being evident. From hydrocele of the spermatic cord, sometimes with much difficulty, and therefore it requires here particular attention. In every case of tumor in the testes where the most perfect certainty is not obtained, and when it is necessary to have recourse to an operation, the surgeon ought to proceed as in a case of real hernia.

The treatment of bubonecele is the same with that already advised in the treatment of hernia in general, only making allowance for the situation of the disease. In attempting the reduction by means of the hand, the pressure should be obliquely upwards and outwards, corresponding with the ring of the abdominal muscle. In performing the operation, the patient should be laid on a table, with his head and body almost horizontal, whilst at the same time his buttocks are somewhat elevated by pillows placed beneath them. The legs hanging over the edge of the table ought to be separated, so as to admit the operator between them; and should in that situation be firmly secured by an assistant on each side, who should take care to keep the thighs so far raised as to relax all the abdominal muscles. The parts being previously shaved, an incision must be made with a common roundedged scalpel through the skin and part of the cellular substance, beginning at least an inch above the superior end of the tumor, and continuing it down to between two and three inches bele v the ring. Although, in by much the greatest proportion of hernial swellings, the spermatic vessels lie behind the protruded parts, yet on some occasions they have been found on the anterior part of the tumor; so that in order to avoid the risk of wounding them, as soon as the skin is divided, the remainder of the operation should be performed in the most cautious manner, care being taken to avoid every large bloodwessel which makes its appearance. The ring

must now he laid distinctly in view; a small portion of the protruding sac must also be exposed; after which the directory is to be introduced between the ring and the sac, placing the point of the instrument obliquely upwards and outwards. A blunt-pointed bistoury is now to be introduced into the groove of the directory, and by it the ring is to be dilated till the point of the finger can be introduced. The directory is now to be laid aside, and the finger used in place of it through the rest of the operation. After the operation is finished the dressings are to be applied, and the whole secured by a T bandage, or suspensory bag, properly stuffed with soft lint.

OF HERNIA CONGENITA.

The testes in the foetus are, till near the time of delivery, lodged in the cavity of the abdomen. When they descend into the scrotum, they push before them a portion of the peritoneum, which afterwards forms the vaginal coat. The passages by which they descend are soon shut up; but sometimes a portion of some of the abdominal viscera, passing down, forms that species of hernia to which new born infants are liable, termed by Haller the hernia congenita. The testicle and protruded intestine being here in contact with one another, the tunica vaginalis testis forms the hernial sac. A hernia congenita may be distingushed in an adult by the bowels pushing down between the sac and the fore part and sides of the testicle, so as often in a great measure to conceal it; whereas, in the common hernia, every part of the testicle can be felt distinctly; and it is of material use to make the distinction, because in whatever manner we operate in hernia congenita, unless we take the utmost care to exclude the air, there will be a more violent inflammation and greater distress than in common cases, because the testicle will partake of the inflammation. In the treatment of ruptures, of the congenital kind, little difference occurs from the management of the common scrotal hernia; only a truss ough never to be applied to infants, unless the testicle can be felt in the scrotum, after the contents of the hernia have been reduced; as it would entirely prevent the descent of the testicle, which yet remains in the abdomen. OF HERNIA CRURALIS, OR FEMORAL HERNIA.

The seat of this species of hernia is upon the upper and fore part of the thigh; the protruded bowels passing out at the same opening through which the large blood-vessels of the thigh are transmitted from the abdomen, and of consequence under that part of the tendon at the under end of the abdomen known by the name of Poupart's or Fallopius's ligament. Sometimes the bowels which protrude are situated immediately over the femoral vessels, sometimes on the outside of these, but more frequently they lie upon their inner side. The disease is more frequent in women than in men, on account of the width of the female pelvis, and of consequence the length and laxity of the ligament. The femoral hernia is more in danger of being confounded with inguinal hernia than with any other; the tumor, however, is deeper, and the