the sac to the contiguous parts, considerably to impede my attempts. On handling the sac, I thought it much thickened; and I now made some attempts to separate it from the gland with my fingers, but found this also impractica

ble.

Being now satisfied the object of the operation was attained, the integuments were brought together over the gland and sac, by three stitches of the interrupted suture, assisted by straps of adhesive plaister, so as completely to unite the wound by the first intention. Nothing further occurred relating to the cure, of any importance. The wound healed kindly, and was attended with very little pain; and in twelve days was completely cicatrized.

The pulse, at the time of the operation, was at 122; an hour after, at 108; and the day following, at 96. In short, she rapidly regained her health.

It may be a matter of surprise, that the gland was not removed at the time of the operation, on account of its diseased state; but as it had preserved its texture, and exhibited no marks of disease, save enlargement; and as extirpation could not have been attempted, without probably leaving a part of it behind, or otherwise wounding the sac, I therefore suffered it to remain, being persuaded the operation would effect some change towards its annihilation or dispersion. This idea was eventually realised; for on the 15th of September, 1808, I was called to this pa tient, who complained of great pain in the hernial sac, but which was empty. Her pulse was at 103; she was thirsty; and her tongue a little furred. She was also excessively sick, but had not vomited, yet bad retched a few times. Half a drachm of the vitriolated inagnesia, dissolved in a table-spoonful of cold water, was ordered her every hour. In ten minutes after taking the first dose, her pain and sickness ceased; and after repeating the medicine a few times, it operated, and she ailed no more. On examining the groin, I could perceive no remains of the gland. She informed me, it vanished in a few weeks after the operation; and that the hernia now descended and receded, accordingly as it was favoured by the position of the body, more readily than formerly. From which time, to the present, she has worn a steel-truss, and continued in good health.

This case affords no data for determining the effects of pressure, for it is plain, from the frequent and ineffectual attempts of the patient formerly, at different times, to return the hernia, and the circumstance of the sac adhering

to

to the inguinal gland, which prevented it being pushed up towards the stricture, that no pressure, on the principle of pressure, formerly recommended, could have much effect.

I have long been impressed with an idea, that under some circumstances, the hernial contents might with propriety be returned into the abdomen, without a division of the sac, being sensible of the advantages that would accrue from, and the inconveniences that would be obviated by, such a practice. Under this conviction, I have ventured to deviate from general custom; and although I have great, and almost general authority against me, yet the few observations I shall adduce on this practice, will, I trust, not only apologize for my conduct, but may call forth the more experienced part of the profession to a further discussion of this subject.

As

Two ostensible advantages apparently result from a division of the hernial sac. The first is, the greater certainty of removing the stricture; the second is the opportunity afforded for inspecting the hernial contents. to the division of the sac, for the first intention, I believe it may frequently be obviated by the stricture being otherwise removed; and as the method of dividing the sac is counterbalanced by such important disadvantages, which are nothing less than rescuing the patient from one danger and exposing him to a second, any method that will effect the one object and prevent the other, is a desideratum in Surgery of no small moment.

What has confirmed modern surgeons in their idea of the necessity of uniformly dividing the sac, seems to have arisen from a contrary practice, adopted many years ago by somé eminent surgeons, but which grew into disrepute, principally by their not attending strictly to the circumstance of ascertaining whether the stricture was overcome. They imagined, when the tendon of the oblique muscle was divided, that the stricture was of course removed. They found, however, on examining into the cause of the miscarriage, which in some instances happened, that the neck of the hernial sac in general formed the stricture, and was the source of the mischief. Hence, the old method of dividing the sac was reverted to promiscuously, without adopting or retaining any modification of the new prac tice; the utility of which, had, in many instances, been conspicuously evident.

By the non-division of the sac, the patient is certainly exposed to some risk from the neck of the sac forming the stricture, as has sometimes been the case; and it is pretty

certain,

certain, that in a great majority of the patients, who have died after the operation, where the sac has not been opened, it has been from this cause; to ascertain and remedy which, I believe in most cases, will not be difficult. After dividing the integuments, and properly exposing the sac, I would desire an assistant gently to pinch up the sac with his finger and thumb, in order to prevent it slipping into the abdomen; a circumstance that might possibly happen, but as the sac most generally adheres to the surrounding parts, this part of the operation will mostly be rendered unnecessary. Immediately after this, I would divide the supposed stricture; namely, the tendon of the oblique muscle in the inguinal, and Gimbernat's ligament in the femoral hernia. This being effected, the protruded parts, especially if the patient be laid in a posture favourable for reduction, will in most instances readily recede. The attainment of this object is generally known by a diminution of the pain and tumour, attended frequently with borbo rigmi, and succeeded by an alteration in the countenance, and particularly a sanguine manner in which the patient seldom fails to express his relief; but if, on the other hand, after waiting a while, any doubts of the stricture being removed still remain, it will be then necessary to open the sac. The few solitary instances we meet with in surgical authors, where some part of the hernial contents form the stricture, can have little weight towards pointing out the necessity of opening the sac, when set in opposition to the disadvantages resulting from that part of the operation.

Hence, if on dividing the tendon, every symptom of strangulation cease, together with a reduction of the her nia, and the sac at the same time remains unreduced, we may rest assured that the stricture is not in the neck of the sac. If the circumstance of the hernial contents forming the stricture, were not a very rare occurrence, a mode of operation, perhaps, preferable to the above, might be suggested; this scheme, though not founded on experience, is the result of some reflection. The method which I allude to for determining whether the stricture be in the protruded parts, is as follows. After the integuments in bubonocele are divided, and the sac properly denuded, the patient's body is to be elevated into a hal erect posture, so that the axis of his trunk may form an angle of about forty-five degrees with the table on which he is laid. By this position, the hernia will be prevented from spontaneously ascending. The tendon is next to be divided, and in such a manner, if the cause of the mischief, as to leave

no

no doubt of the stricture being removed. If all the symp toms of strangulation should now cease, it is conclusive, that the stricture is in the tendon of the oblique-muscle, and the hernia is to be returned into the abdomen, as be. fore described. If, however, after waiting a while, any doubts of the stricture being removed are still entertained, a fair opportunity offers for opening the sac, for the purpose of discovering the stricture. The advantages which this method seems to possess, are sufficiently obvious. First, it ascertains whether the stricture is in the tendon, or in the sac, or some part of its contents; if in the former, then the hernia may be returned, without a division of the sac, where the object is to remove stricture only; if in the latter, then the real necessity for opening the sac is indicated.

In irreducible hernia, in an incarcerated state, by the non-division of the sac, we have fewer means in the operation of ascertaining the removal of the stricture, than when the parts are capable of being returned into the abdomen. The feelings of the patient, and a suspension of the symptoms, are our principal criteria. Notwithstanding these scanty means of discrimination, before we expose our patient to the consequences of dividing the peritoneum, we ought to wait a while, as before mentioned in reducible hernia, after the division of the integuments and tendon if the circumstances of the case will admit it, and if a total cessation of all the unpleasant symptoms should ensue, for, we will suppose, the space of an hour, we should not hesitate to unite the wound by the first intention.

This practice of waiting may appear trifling to the patient or bye-standers; but to the humane surgeon, who is fully impressed with the consequences dependent on his conduct, and who wishes to avoid incurring danger, rather than try the experiment of overcoming it, this practice, I hope, will have its due weight. As this method also can only be advisable, when our object is to remove stricture, and as this must often succeed, without exposing the patient to those consequences arising from a division of the sac, such an attempt, guided by caution and judgment, ought in my opinion to precede this most serious part of the operation.

The reasons for not opening the sac, in reducible, apply equally or with greater force to irreducible hernia. For in the latter, as soon as the stricture is removed, we are to consider the prolapsed parts, either in a state of inflamma

tion

tion or gangrene. If in the former, then the advantages will be greatly in favour of not opening the sac, for reasons that are obvious. If, on the other hand, mortification exist within the sac, it is in general confined to parts below the ring; and the enveloping covering will impart such warmth to the diseased hernia, as cannot fail not only to arrest the progress of mortification, but to expe dite the process of separating the gangrenous from the sound parts. Hence, as this business cannot be effected without suppuration, a sanious matter will form, and ac cumulate in the sac, which, if not evacuated by an artifi cial opening, and left to nature, will be discharged by a spontaneous rupturing, attended with considerable loss of substance. On the contrary, if the practice of opening the sac be adopted, at the time of the operation, and the morbid part of its contents be removed by the knife, the conse quences are frequently fatal; and, if even they are only in a state of inflammation, from their being previously thickened and diseased, any new stimulus applied, or additional violence done to them, must cause the subsequent inflammation to be alarmingly great.

The advantages necessarily resulting from this unusual mode of operation, as above recommended, are such as have perhaps not been duly appreciated. Air, when admitted into the abdomen, has been long considered as deleterious; and the division of the sac, in a state of irritation, which is the peritoneum itself, must in conjunction with this circumstance, be sufficient greatly to aggravate all the distressing symptoms which existed at the time of the operation. Whoever has seen the difference betwixt wounds in the abdominal covering, where the peritoneum has been divided, and otherwise, will be satisfied, this membrane cannot be injured without an increase of subsequent inflammation; but the most convincing of all arguments will be, the contrast between these cases, where the operation has been performed in the usual way, and those where the taxis has succeeded. This difference in their result is so striking, as may draw the attention of surgeons, at some future period, to a more able consideration of this subject. Mr. Wilmer gives us a number of apparently desperate cases, where the hernia was reduced without the assistance of the knife, and the patients ailed no more; and he also gives us other cases, where the operation of dividing the sac was performed in the usual way, and a great proportion of the patients died. Mr. Hey seems to have been no more successful in his practice; yet both these gentlemen, as well

as