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OBSERVATIONS







    ON
BUBONOCELE. 
 
AN INAUGURAL DISSERTATION
   THAT SPECIES  OF HERNIA

                 CALLED


         BUBONOCELE;

               SUBMITTED

          TO THE EXAMINATION
                 OF THE

   REVEREND JOHN EWING, S. T. P. PROVOST;
               THE TRUSTEES
AND MEDICAL FACULTY OF THE UNIVERSITY OF PENNSYLVANIA}
         ON THE EIGHTH DAY OF JUNE, 1801,

  FOR THE DEGREE OF DOCTOR OF MEDICINE.


         BY SAMUELJ^ARTLEY,
    OF PHILADELPHIA, HONORARY MEMBER OF THE PHILA-
       DELPHIA MEDICAL AND CHEMICAL SOCIETIES.
........................ut si
Caecus iter monstrare velit.   hor.
PHILADELPHIA
PRINTED FOR THE AUTHOR, BY HUGH MAXWELL,
           COLUMBIA-HOUSE.
1801.
 
 
TO PHILIP SYNG PHYSICK, M. D. &c.




                THIS





         DISSERTATION




             IS INSCRIBED,




     AS A SMALL BUT GRATEFUL TRIBUTE



                 OF




       RESPECT AND ESTEEM,




  IOR THE MANY OBLIGATIONS




     SO GENEROUSLY CONFERRED,




         AS WELL AS




  VALUABLE OPPORTUNITIES OF INSTRUCTION




            RECEIVED,




       DURING THE STUDIES OF HIS




             FRIEND AND PUPIL,




                   SAMUEL GARTLEY. 
 
BUBONOCELE.
        1 HE term Bubonocele, the subject of the
present Dissertation, appears to bederivedfrom the
two following Greek words, B««£*y, which signifies
the Groin, and KnXi,, a Tumor; and might, from the
strict etymology of the word, be applied to every
kind of swelling situated in the groin.   But sur-
geons have agreed to define it to be a tumor, or
swelling, beginning in the groin, and descending,
by degrees, into the scrotum, in men, and into the
labia pudendi, in women; occasioned by a protru-
sion or descent of some part, or parts, of the abdo-
minal viscera, through the ring  or slit formed by
the tendon of the external oblique muscle;  which
tumor is said to afford  a different sensation to the
touch,  according to the difference of its contents.

    For the better understanding the nature, situa-
tion, and  method  of curing this disorder, it  will
be proper, before proceeding any further, to give a 
                   [   *   ]
short, anatomical description of the parts, in which
it takes place.  These are, a portion of the abdo-
minal muscles, the peritoneum, spermatic vessels,
and testicles.

    The  fleshy boundaries  of the abdomen  are
formed by five pair of muscles, viz. the obliqui
externi,  obliqui interne, transversales, recti, and
pyramidales.  It frequently happens, that the pyra-
midales are  wanting,  and, as  the obliqui externi
are alone concerned with  the present subject, we
shall confine our description to them, more parti-
cularly.

    The external oblique muscles form a covering
for all the anterior and lateral parts of the abdomen,.
being  bounded, above,  by  the  serratus  major
anticus,  and  pectoralis major; on  the  posterior
side,  by the latissimus dorsi; and below, by the
margin of the pelvis.   The fibres of the tendons of
each  muscle meet and interlace at the part called
lineaalba, which is nothing more than a whitish ap-
pearance, extending from the xiphoid cartilage to
the symphisis pubis,  occasioned by there being no
 muscular fibres under them at this particular place.
 It originates from the eight lower ribs.   On the
 fifth, sixth, seventh and eight ribs, it makes digita-
 tions  with  the serratus major anticus; and, from
 the four lower ribs, it arises under the latissimus
 dorsi.   The pectoralis major generally sends a slip
 of fibres downward, which are inserted into a part 
[   9   ]
trf the tendinous expansion from the oblique mus-
cle; this is generally very narrow.   I'he tendon of
this muscle, though commonly said to be inserted
into the linea alba, yet, in fact, the tendinous fibres,
on one side,  meet, and  interlace with the same
fibres on the  other, from the symphisis pubis to
the xiphoid  cartilage.   Another portion of the
tendinous fibres, is inserted into the os pubis, near
the symphisis, and the rest are inserted into the
spine of the os illium.   Generally speaking, the
direction of this muscle is from above, downwards
and forwards; but, to be  more particular, we shall
observe, that  the upper fibres are nearly transverse;
as they descend they become more oblique, and
those, at last, which arise from the lower ribs, are
nearly in a perpendicular direction.   The muscles
contiguous to this, are the pectoralis major,  on a
 part  of the upper and fore side; the serratus major
 anticus, on the upper part of its origin; and behind
 its origin it is covered by a portion of the latissi-
 mus dorsi.  There are three lines in the tendon ol
 this  muscle,  which have each received different
 names, viz.  the  linea  similunares, linea alba,
 and  linea transversales.  The first extends to the
 margin of the chest, down to the brim of the pelvis,
 on the outside of the recti  muscles; the second is
 in the middle of the belly;  and the last are trans-
 verse tendinous intersections of the recti muscles.
 All  these appearances arise from the same cause,
 viz. from there being no muscular fibres under the
  tendon at those parts, so that it appears whiter than
                         B 
[  10   ]
 elsewhere   It is  through  the  tendon  of this
 muscle, that  the  spermatic  chord passes to the
 testes,  in men, and  the round ligaments to the
 womb in women.   The part  through which these
 pass, is commonly  called the ring of the external
 oblique muscle, which, however, conveys a wrong
 idea, as it is nothing more than a mere split in the
 tendon.   It is not however, a natural opening, be-
 cause a number of tendinous fibres are continued
 down over the anterior surface of  the spermatic
 chord, forming a sort of theca for it.  We  may
 observe, that the lower part of this tendon is thick
 and strong, from a collection of these fibres; and that
 just about the ring there are some, running trans-
 versely with respect to the others, which strengthen
 exceedingly this otherwise weak part. It was said,
 thataportion of thistendonwasinserted intothe spine
 of the illium, but, it  must be further observed,  that
 it is not lost there,  but  extends downwards over
 the muscles of the thigh.  From the anterior supe-
 rior spine of the illium, a number of these fibres are
 stretched across to  the os  pubis, and are folded
 inwards, particularly as they approach the os pubis.
 This  is called  Poupart's ligament, from the  cir*
 cumstance of his having been the first who des-
 cribed it.  It may, however, be observed, that this
 is  not improperly called a ligament, for the only
difference between tendon and ligament is, that the
tendon is attached at  one  end to muscle,  and at
the other to  bone,  cartilage,  &c. and ligament
only connects  bones  together.   There is like- 
[   11   ]
wise, in the fore-part of this tendon,  an open-
ing, called umbilicus.   The  fibres are here cir-
cular; through this the umbilical arteries and vein,
pass into the abdomen of the foetus.

    If both these muscles act at  once,  the  effect
will be, that of compressing and  diminishing  the
abdomen, and thereby pressing  on  its contents;
they will also bend the pelvis to the chest,  if the
chest be fixed, and the chest to the pelvis,  if the
latter be fixed.  If one acts, it will give a rotatory
motion to the chest on the pelvis, if this is  fixed,
and vice versa.

    The internal surface of the abdomen, as well as
every  other  part of  that cavity,  is lined with  a
smooth and  somewhat elastic membrane, termed
peritoneum, which, after having covered the cavity,
is continued or reflected over all the viscera, so as
to give an external coat to each.

    The testes in the foetus, till near the approach
of birth, are lodged in the cavity of the abdomen,
immediately below the kidnies, on the fore part of
the psose muscles, and by the side of the rectum.
Where this intestine passes down into the cavity
of the pelvis they are covered by the peritoneum, as
the rest of  the  abdominal viscera are, except at
their back part,  where it is  reflected from  them,
at which place their blood-vessels, nerves, &c. en- 
                   [   12  1
 ter.  To the lower end of each testis and  epidi-
 dimis, is  attached, the largest end of a ligament,
 which is something of the shape  of a pyramid,
 called gubernaculum testis.  This ligament runs
 down behind the  peritoneum to the abdominal
 ring, through which it passes,  and still diminish-
 ing in diameter,  it descends into the scrotum and
 is united to the lower part of it.   This ligament
 serves as a director to the testis in its descent, and
 the largest end may be useful in dilating the  abdo-
 minal ring.

    The testes, in most cases, descend intothescro-
 tum, about three or four weeks before birth; in some
 instances sooner, in others later ; in a  flew they re-
 main in the abdomen,  or, at least, within the abdo-
 minal ring through the whole course of life, but this
 is uncommon.

   The peritoneal covering, which the  testes haver
 whilst in the abdomen, retains its firm  attachment
 to them during their descent, as well as afterwards,
 and forms their immediately investing  membrane,
 called tunica albuginea. As the testes descend they
 carry along with them that part of the peritoneum
 which, in the abdomen, was reflected from them;:
this must necessarily form an additional covering..
Immediately after their descent, that portion of the
peritoneum, which  they carried  down, forms a
canal, leading to the abdomen. But this is not long
the case; for,  soon after the  testes have reached 
                   [13  ]

their destined situation, the upper part of the canal,
in a short time, begins to contract and unite.  This
contraction and union is continued downwards, till
it comes near the testicle, where the disposition for
such an union does not exist; here it loosely enve-
lopes the testicle, except at its back part, where it
is reflected off the tunica albuginea :  this  loose
covering, or bag is what is called the tunica vagi-
nalis testis.

    The testes, and their investing membrane, just
described, are contained in the scrotum,  which
consits of the common integuments, and a loose
cellular  membrane,  called dartos.   Thus  have I
attempted to give  as  concise a description of the
anatomy of the parts, as the nature of the subject
would admit.

    We have already observed, that Bubonocele is
occasioned  by  a  protrusion of  some parts of the
abdominal viscera through the ring of the external
oblique muscle, so as to produce an evident and
preternatural swelling in the groin.   The viscera,
which are,  most  commonly,  thus protruded, are
some part of the intestinal canal or omentum.

    As aH the internal surface of the abdominal
 muscles are lined  by the peritoneum, it is evident,
that the protruded parts, in  their passage out of
 the abdomen, must either break through the peri-
 toneum, or carry a portion of that membrane along 
[  14   ]
 with them.  Dissections, however, prove, that the
 peritoneum is never torne, but is simply elongated,
 and pushed  before the viscera composing  the
 tumor, forming,  what is called, the hernial sac.
 This sac, which,  in recent herniae, is very thin, is,
 on the contrary,  in those of long  standing,  ex-
 tremely thick, owing, perhaps, to an extravasation
 of coagulating lymph ; as this portion of  the peri-
 toneum is now necessitated  to  sustain  a greater
 weight than it did when the  protruded intestines
 were within the cavity of the  abdomen.

    The causes which produce hernia are various,
 but it is most generally induced by such actions as
 diminish the abdominal cavity; amongst these are
 reckoned, violent coughing, crying, &c. But above
 all, and especially in adults, it is most frequently oc-
 casioned by violent bodily exertions; as strainingto
 lift heavy weights, jumping, &c.  It is evident, that
 these must operate, by exciting violent  pressure
 upon the intestines, from the strong  contraction of
 the abdominal muscles and diaphragm.

    The  symptoms of this  disorder  are   more
 or less violent,  according to the nature of the
viscera which descends, and  especially to the de-
gree of strangulation attending it.  Thus a protru-
sion of omentum alone,  is attended with less dan-
ger than a protrusion  of any part of the intestinal
canal;  besause the omentum is much less  essential
to life than this last mentioned part.  Yet,  when 
[   is   ]
the pressure upon it is sufficiently violent to ob-
sruct the free circulation of the part, and if this
pressure be not soon  relieved,  there is certainly
 great danger  of mortification  ensuing,  which
would be attended  with symptoms as fatal  as in
any other part of the body.  Indeed, it is this  stric-
ture alone,  which creates the danger, and not the
mere descent of the bowels ; for instances  daily
 occur, where large portions of intestine have con-
 tinued, for  a great length of time, within an hernial
 sac, performing all their functions in a proper man-
 ner,  until, from some circumstance or  other, a
 strangulation takes place, attended with all the usual
 bad symptoms that generally accompany this com-
 plaint.  It has been a matter of dispute,  whether
 the disease first  originates in the gut itself,  or in
 the ring; that is, whether strangulation takes place
 in consequence of anaffection of the ring itself, or
 from the  intestine  first becoming  inflamed and
 afterwards  strangulated.  The former of these opi-
 nions I think best founded; for cases frequently
 occur where the patient, without any previous in-
 disposition whatever, is suddenly  attacked with
 strangulated hernia, in consequence, evidently, of
 some violent exertion, which, if operated upon, is
 found to be owing to a stricture of that part of the
 tendon, forming the ring, upon the protruded parts;
 for if this tendon be dilated, the parts immediately
 expand, and  every symptom of strangulation is
 removed.  Again, if the disease originated from an
 inflammation of the intestine, the reduction would 
                  t   I6  ]
not be attended with a relief of the symptoms, be-
cause those of inflamed intestine would still remain.
But we know, that this is far from being the case;
reduction of the  protruded intestine instantly, in
most  cases,  and,  perhaps, in all recent ones, sets
the patient at ease, though previously labouring
under the most excruciating pain. It is true, inflam-
mation of the intestines is attended with symptoms
very much resembling strangulated hernia;  but
these never cease instantaneously, as those of hernia
almost always do, after reduction of the protruded
parts.

    The danger attending Bubonocele, as has been
observed, proceeds from an obstruction, produced
in consequence of a stricture made upon the in-
testines,  at the abdominal ring.    As soon as this
pressure becomes considerable, the swelling, which
takes place  in consequence of  the  obstruction
of circulation and from inflammation,  augments
the disease ;  for  the intestines, being  unable to
propel their  contents, obstinate  costiveness en-
sues.   The faeces being accumulated along the
canal, the  stomach sympathising with the part
affected,  excessive nausea and vomiting are  in-
duced, accompanied with violent pain all over the
abdomen, but more particularly at the  obstructed
part,  and at the umbilical region.   This pain is
always increased by coughing, sneezing, &c :  the
pulse in this state is generally hard and tense.  If
these symptoms be not soon relieved, by a removal 
[  17  ]
of the stricture,  the vomiting becomes more viti-
lent; the pain increases prodigiously; and a great
degree of tension takes place in the abdomen, to-
gether with an increase of restlessness, fever, and
anxiety. These continue for some time, and are suc-
ceeded by evident symptoms of mortification. The
pulse then  sinks rapidly ;  the thirst is excessive;
the extremities become cold, attended with clam-
my sweats; the hernial tumor subsides very much;
the ring of the abdomen, losing its tension, the in-
testines are frequently spontaneously reduced; the
patient  then discharges freely by stool; the tense-
ness of the abdomen subsides, together with an
abatement of the pain; the vomiting ceases, but is
succeeded  by a hiccough, which is usually a fore-
runner of speedy death,  and this sometimes takes
place in so unexpected a manner, that it is often
thought by the patient, as well as his attendants,
that he is getting the better of all his complaints.
In short,  he dies with all the symptoms  which
usually attend mortification of the intestines.

    It must, however, be observed, that when the
omentum alone is protruded, all those violent symp-
toms above enumerated will not occur; for though
even here the symptoms may be very distressing
and alarming,  yet death rarely ensues.   It  may,
therefore, be of consequence to discover, if possi-
ble, whether the disease be occasioned by a descent
of omentum or intestine ; which, it is said, may be
determined bp the following signs, viz.  when the
                       c 
                   i  is   ]
tumor is formed by omentum only, it feels soft and
flabby, yielding to the finger like dough, without
that smoothness and elasticity perceptible in those
cases where the intestine is alone concerned.  But
this is, by no means, to be depended upon ; for a
sensation, similar to this, obtains in old gut-hernise
of long standing, when there happens to be a con-
siderable collection of hardened faeces in the pro-
truded parts.   It must, likewise, be very difficult
to discriminate by means of this test alone, between
a simple omental  tumor, and  one formed by a
protrusion of omentum and  intestine,  as the sen-
sation communicated by the touch from both are
very much alike.   There is, it is said, little or no
pain in handling omental tumors, the  contrary of
this  is  the  case  when  intestine is  protruded.
Among the other  distinctions  which have been
made, between  those tumors, is their difference in
size,  form,  &c. but these we shall pass over, as
there are objections to all of them.  Indeed, the
only just and certain criterion, that we are acquaint-
ed with, to judge of their difference, is that  of ob-
stinate costiveness, which almost always  attends
those of the intestinal kind when strangulated, and
which cannot frequently be the case when omen-
tum is alone concerned.

    Bubonocele has sometimes been confounded
with complaints of the groin and scrotum;  such,
for instance, as the venereal bubo, and other swel-
lings of the groin ; sarcocele; the different species 
L   19  ]
of hydrocele, &c. but, from all these, it may rea-
dily be distinguished; and the marks of distinction
are so very obvious, that I think it unnecessary to
describe them here.

    When we  first discover  this swelling  in the
groin, we should direct the patient immediately to
lie upon his back, for its reduction; which, inmost
recent cases, will take place while he is in this situ-
ation.  But if it cannot  readily be effected by this
means,  then we ought to have recourse to the ope-
ration of the taxis, presently to be described. After
the protruded parts are completely returned into the
cavity of the abdomen,  we ought to endeavour to
prevent any future descent.  The only means which
we are acquainted with, that can be depended upon,
for this purpose, is the application of a well adapted
truss;  this ought always to be of the steel-spring
kind, for if made of any kind of soft materials, it
can never be kept rightly fixed.   In the application
of the truss, it is absolutely necessary,  that the pad
or bolster should bear properly against the opening
upon which it is placed, or there will be danger of
a portion of intestine slipping out, and in this state
it might be materially injured by  the pressure of
the pad.

    When, however, the protruded parts have been
in a state  of strangulation, before the surgeon is
called in, immediate attention should be paid to 
[  20   ]
the relief of those symptoms which usually accom-
pany it.  The only proper methods for this pur-
pose are,  either to procure the reduction of the
intestine, through the abdominal ring, by which it
descended, without the interposition or assistance
of any chirurgical operation, strictly so called, or,
if this cannot be effected, then to divide the tendon,
forming that ring.  This last is  what is usually
termed the operation for Bubonocele,  and should
not be resorted to, until most of the following me-
thods fail.

    The manner, in which the reduction of the
strangulated viscera should be attempted is as fol-
lows : First, the patient should be laid on his back,
with his thighs and breech raised considerably
higher than his head and shoulders.  The surgeon
is then gently to press the tumor with his  hands
and fingers, obliquely upwards, and outwards to-
wards the os illium, so as to correspond as nearly
as possible to the opening in the external oblique
muscle.  When the tumor is of any considerable
size, or when it descends into the scrotum, pres-
sure as here recommended,  is most conveniently
made by grasping the swelling  with one  hand,  at
the bottom, while, at the  same time,  he endea-
vours, with the fingers of the other hand, to push
forward the contents at the superior parts; this  is
what is usually denominated the operation of the
taxis.  When, however, this is found insufficient
for the reduction of the tumor,  we must have im. 
[  21   ]
mediate recourse to the assistance of other reme-
dies. The first, and, perhaps, the most efficacious
of these, is blood-letting, which ought to be suffi-
ciently copious to  induce  fainting, it being well
known, that this is attended with a general relax-
ation of every muscular part of the body.  So effec-
tual, indeed, is this  remedy, that it frequently
happens,  when patients are in this state, that the
protruded parts return spontaneously. At all events,
the surgeon ought to seize this favourable oppor-
tunity to  endeavour to reduce the parts by means
of pressure.

    Injections,  composed of an infusion of tobacco
in water,  are invaluable remedies in strangulated
Hernias.  If not equal, they,  at least, rank next in
efficacy to the lancet, producing, like this, a com-
plete state of relaxation over the whole body. In-
deed, they are the only remedies, besides blood-
letting, which we can make use of here, that have
this property in  so  eminent  a degree: they also
possess somewhat of a purgative quality.

    It has been commonly recommended,  to use
tobacco in form of smoke; but as this requires, for
the proper exhibition of it, a particular kind of
machine,  which  is  seldom at hand;  and  as it has
no superiority,  whatever, over the simple infusion,
we think the latter of these ought to be preferred.
This infusion may be made by boiling one drachm
of dried tobacco,  for fifteen or twenty minutes, in 
[  22   ]
one pound of water; we do not, however, recom-
mend this  to the exclusion of other injections, as
many of them at least deserve a trial.

   Cathartics are of great efficacy,  and ought
always to be used as auxiliaries to the other reme-
dies.   Jalap  and cream  of tartar, are the best
adapted to this  purpose.   When there is great
nausea at the stomach, a few drops of oil of mint
may be added.

   The  WARM  BATH,  POMENTATIONS,  and
emollient  poultices.   The  first of these is
of great utility,  and much  advantage has been
derived from it in this disorder.  While  the
patient is immersed in the bath, the surgeon ought
to attempt the replacement of the  protruded parts
by the taxis.

   The utility of warm bathing may be explained
by the universal  relaxation which  it is known to
produce.  Indeed, it has often happened, that the
intestine has gone up while the patient  was in the
bath.  Fomentations and emollient poultices ap-
plied to the ring itself, are now seldom  employed.
It must be very evident that they can have but lit-
tle or no influence upon the constricted tendon, as
it always lies too deep to be within the reach of
any local applications of this nature.  If however,
the warm-bath is not  attended with the desired
effect, than we should have recourse to 
                  [   23  ]
   Cold applications, applied to the ring, and
tumor itself, which have, in many instances, been
attended with success.  By the use of these, the
size of the tumefied intestine is much diminished,
and its reduction more easily accomplished.  The
cold applications, for this purpose, should consist
of ice or snow; either of which may be applied in
a bladder, to the affected part.  For this mode of
application I am indebted to our ingenious and
learned  professor  of  anatomy,   doctor  Wistar;
under whose direction, I saw it used with remarka-
ble success, in a case  which occured,  about two
months ago, in the Pennsylvania Hospital. When
neither  ice nor snow  can be procured,  we may
use, in lieu of them, a recent solution of sal ammo-
niac in  vinegar, which produces a considerable
degree of cold.

    Opiates.   It has sometimes happened that,
after all these remedies have failed, a large opiate
has procured the desired relief.   As the stomach,
however, is almost always so much affected as to
prevent the exhibition of them by  the mouth,
they may in  such instances, be advantageously
applied in the form of injections.

    If, after all the above methods have been tried,
the reduction should still be found  impracticable,
the only resource which we have remaining,  is
the division of the parts, producing the stricture,
by a chirurgical operation.   A great deal of difti- 
[  24  ]
 culty exists in determining the precise time, when
 to proceed to the operation; perhaps, however, in
 those cases attended with very violent symptoms,
 it would be wrong to spend more than twenty-four,
 or thirty-six hours,  at farthest,  in attempting to
 reduce it by the above mentioned remedies.

    I know, in opposition to this, it may be be said,
 that many cases occur where the gut has been in
 a state of strangulation,  accompanied with every
 untoward symptom, for the space of five, eight,
 or ten days, and has, at last, yielded to the treat-
 ment just recommended; but were this  to happen
 even more frequently than it is  known to do, I
think it would, by no means, compensate for the
 loss of a single patient, whose life might have been
 saved  if the operation  had been performed  in
time.

    From what has been  already  said,  concerning
the nature of this disease, I think it will evidently
 appear, that in common cases the only obstruction
to the reduction of the contents of the sac, is in the
ring itself, and to dilate this is all that is required.
 Certainly,then, it would be wrong to suffer a patient
 to run the smallest risk of being attacked with those
 fatal symptoms which usually attend strangulated
 herniae, without attempting an operation, in itself
 quite simple,  and when performed, with proper
 care, and  in due time, will be generally attended
 with success. 
C  25   ]
   When the operation is concluded  upon, the
patient should be advised, first to empty his blad-
der entirely,  in order to afford as much space as
possible for the return of the protruded parts, and
the hair should be shaved from off the lower part
of the belly.  He is  then to be laid on a table of
convenient height, and in a room properly lighted.
His head  and body  should be almost  horizontal,
whilst, at the same time, his  thighs and buttocks
are somewhat elevated by pillows placed under
them.   The legs, hanging over the edge of the
table, ought to  be firmly secured by assistants,
and opened so wide that the surgeon may stand
between  them.   The  thighs ought  to be  suf-
ficiently raised to relax the  abdominal muscles;
after which,  the operator is to make an incision
with  a scalpel,  about  four  inches  in  length,
through the skin and cellular substance, begin-
ning about two inches above the upper part of the
swelling,  and continuing it to the same length be-
low the ring.  He then continues to divide every
part of the cellular substance, and whatever tendi-
nous bands he may come across, with the  greatest
attention; for by this method  of proceeding, if
there be no preternatural formation of parts, which
indeed is rarely the case, he will always be able to
 avoid mischief.  The ring must now be  brought
distinctly into view, with a small portion of the
 protruded sac;  after which the operator  must
 make a small opening with his scalpel, in  the ten-
 don,  about  one inch above the upper  edge of the
                       D 
                   [   26  ]
 ring.   Into this he must introduce a small direc-
 tor, upon the groove  of which the probe-pointed
 bistoury  ought  to be  inserted,  and  make an
 incision through the tendon,  in the direction of
 its  fibres,  beginning from  above downwards,
 until the upper  edge of the ring is divided.   He
 is now to attempt the  reduction of the protruded
 parts,  by the taxis, which may be accomplished
 with the greatest ease, if the strangulation is own-
 ing to the stricture at the ring.   But it sometimes
 happens that  this  is  otherwise;  adhesions hav-
 ing taken place between the gut and sac,  so firm
 as  not  to be disengaged, except  by dissection.
 Concerning the treatment of such  cases  we will
 speak hereafter.  After the operation is finished, the
 sides of the wound are to be brought together, and
 retained so by means  of slips of adhesive  plaster,
 that union, by the first intention may, if possible,
 be accomplished; over this is to be placed a pledget
 of tow, and the  whole  secured by a bandage pro-
 perly applied.

    In performing this operation we  are of opinion,
 that the sac should not be opened, except in those
 cases where we have reason to suspect, that morti-
fication has taken place; or, where the  intestine
 cannot be returned on account of adhesion between
it and the sac; or, from the stricture being  formed
by the thickening of the sac at its neck*.  In judg-
    • In this last case, the tendon at the ring, when laid bare will
be found loose, making no compression whatever, on the hernial tumor. 
[  27   ]
ing of the first of these circumstances, we may, in
a great measure, be guided by the usual symptoms
of mortification, some of which we have already
mentioned.  Inquiring how long the gut has been
in a state of strangulation, before the surgeon was
called in,  would contribute no little in informing
us of the probable state of the strictured parts.
    Adhesions generally take place in those cases
of hernia, which are of long standing, and their
presence may be suspected, from the intestine, pre-
vious to strangulation, not returning when the pa-
tient has been in a horizontal position ;  nor by any
other method  which  he has been accustomed
to make use of for this purpose.  In all those cases
the sac ought to be opened, and should be done in
the following manner : The patient,  having been
secured in the position just described,  the opera-
tor is  to  make an incision,  beginning about two
inches above the ring, and carrying it down to the
bottom of the tumor, dissecting, in the same cau-
tious manner, as we have before advised, until the
sac itself is exposed, which must be opened as
near the bottom of the tumor as possible.   In at-
tempting this, he ought to use the utmost circum-
spection and nicety, by making repeated and slight
scratches with his scalpel, and frequendy searching
with a probe,  until  he finds the perforation is
completed.   In this  manner it may  always be
effected without danger of wounding  any  of the
protruded parts.  As soon as this opening is made
quite through the sac, it ought to be  further en- 
[  28   ]
larged, till it is of such a size as to admit the fore-
finger of the operator's left hand.  Upon this he is
to introduce the probe-pointed bistoury, and divide
the sac its whole length from below up to the open-
ing in the external oblique muscle,  which is next
to be dilated with the probe-pointed bistoury. The
sac being now laid fully open, the parts contained
in it ought to be strictly examined.   If they are
discovered to be sound, they ought immediately to
be reduced,  but if this cannot be done on account
of adhesions, and these adhesions are slight, they
may be easily separated by the fingers, or snipped
with scissors. If, on  the contrary,  they are found
to be so adherent as not to be returned without ex-
tensive dissection, perhaps it would be better to
divide the stricture and let them alone. If any part
of the  intestine is found  to  be  in  a sphacelated
state, and if it does not already adhere to the sac,
we ought to prevent it from returning into the ab-
domen, while in this  state,  by stitching it to the
sac. After the operation is finished, the sore should
be dressed with lint spread with simple cerate, over
which a small pledget of tow is to be laid, and the
whole secured by a proper bandage.

    The patient, on being carried to  bed, should be
so placed as to have the part on which the opera-
tion was performed somewhat higher than the rest
of his body, in order to prevent a return of the dis-
order.   Great attention ought to be paid in keep-
ing the body moderately open ; and should fever 
                   [  29   ]

succeed, blood-letting, together with such antiphlo-
gistic means as are generally employed,  will be
found necessary.

  When the intestine has been found in a morti-
fied state, and the patient should be so fortunate
as to recover,  the diseased portion of gut must
separate from the sound part, and a preternatural
anus will be formed at the groin,  through which
the faeces will be discharged for a considerable time;
but this, for the most part, will not always be the
case; for we will find, that,  in the process of heal-
ing, the sides of the wound will contract, at the
same time that the edges of  the intestine approach
each other,  and unite in such a manner, with the
cicatrix, that the continuation of the canal is pre-
served, and the faeces discharged in the usual way.

   We have observed, that in most cases of hernia,
where the operation is performed in due time, the
intestine may be safely  reduced without  opening
the sac ; the advantage we derive from this, is the
prevention of that inflammation which  frequently
occurs from exposure of this cavity. Many objec-
tions have been made to this mode of treatment,
but none of them apply with more force here, than
they do against  reduction by means of the taxis,
which  is recommended  and supported by all chi-
rurgical writers.

   Upon the whole, it appears to me probable, that
at least, in every recent  case, the patient may be 
[  30  ]
 relieved, without danger> simply by  dilating the
 ring, so that the protruded parts may be reduced.

    I cannot conclude this Essay without acknow-
 ledging myself indebted to each of the professors
 for the numerous opportunities  of improvement
 that I have received from them during my studies
 in this university.

    To doctor Woodhouse I am bound to confess
myself under particular obligations, for the many
friendly admonitions, as well as valuable instruc-
tions, with which he has honoured me.   With
graytude I acknowledge them,  and shall consider
it as a duty, in future,  to deserve their continu-
ance.
THE END. 
 
 
 
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