adhesions, or other causes, they are incapable of being returned, it is termed irreducible. An incapacity of reduction, arising from stricture in the opening through which the viscera have descend. ed, brings it into the incarcerated or strangulated state. The causes of hernia are of two kinds; the occasional, or exciting, which consist of all those, by which the pressure of the abdominal viscera against the sides of the cavity is increased, as in straining, and all forcible actions of the respiratory muscles; and the predisposing, which favour the occurrence of rupture in particular indi,viduals, as an unusually large state of the openings or lax condition of the margins of those apertures. A reducible hernia is an indolent tumour, smaller in the recumbent position, larger in the erect posture; diminishing, or entirely disappearing, by means of pressure; large and tense after a meal, or when the patient is troubled with wind; soft and small in the morning, before he has taken any food; attended occasionally with a rumbling sensation, particularly on his return; and rendered tense when the patient coughs, so as to communicate an impulse to the hand of the examiner. Various visceral derangement, as colic, constipation and vomiting, are occasionally attendant. Uniformity and elasticity of the tumour, together with the rumbling noise, and the feeling of impulse on coughing, show that the case is an enterocele; but if the swelling be compressible, flabby, and uneven, free from tension on coughing, and slow in returning, the contents are omentum. A reducible hernia, although not immediately dangerous, leads to many unpleasant consequences, from its constant increase in size, and the visceral derange. ments that ensue from this cause. It is also constantly liable to strangula tion. In a strangulated hernia, the protruded parts become inflamed, and this affection is propagated over the rest of the surface of the abdomen. Hence pain of the part, and tension of the belly, are early symptoms. An entire suppression of the fecal discharge is also a very leading character. Nausea and vomiting ensue; all the contents of the stomach, and afterwards those of the intestines, down to the stricture, being rejected. The whole system is deranged; there is great anxiety and restlessness, with a small and hard pulse, and cold extremities. At length hiccough supervenes, the pulse is hardly sensible, the respiration weak, and the whole body is covered by a cold and clammy sweat. Mortification and death now speedily succeed. The intensity of the symptoms, and their duration before the occurrence of the fatal event, are modifi ed by numerous circumstances, as the age and strength of the patient, size of the rupture, closeness of the stricture, &c. ; so that a case may terminate fatally within twenty-four hours, or it may be protracted for two or three weeks. Hence the strangulation has been distinguished into the acute and chronic. The treatment of a reducible rupture comprehends the return of the protruded parts, and their retention within the abdominal cavity by means of an appropri ate truss. Various proceedings were recommended by the older surgeons for producing a radical cure, as castration, caustic, the royal stitch, &c. ; but as these expose the patient's life to the most imminent risk, without affording any greater chance of an effectual cure than the use of trusses would bestow, they have gone entirely into disuse. Herniary ban. dages are of two kinds; the elastic and non-elastic. The former are constructed with a piece of steel nearly encircling the body, and termed the spring, by means of which they maintain a constant pressure on the opening, through which the parts protrude. If their use be continued for a sufficient length of time, it even affords a prospect of a radical cure. Since the constant pressure of the pad of the truss keeps the neck of the sac empty, and thereby brings on a gradual contraction and obliteration of its cavity. Non-elas tic trusses are so inferior to the others,. that they are now universally laid aside. As the best constructed trusses will not afford a certain protection from descent of the bowels, the ruptured person should avoid all great bodily exertions; and, if the hernia should descend, he should immediately go to bed, and send for surgical assistance. As an irreducible hernia does not admit of the employment of a truss, the tumour must be supported by a suspensory bandage; and the patient, by temperance in diet, constant attention to the state of his bowels, and avoiding all great exertions, must endeavour to obviate the risk of strangulation, to which he is constantly exposed, and to prevent the increase of the tumour. Confinement to bed for a few weeks, with bleeding, mercurial medicines, purges, and low diet, has some times caused irreducible hernia to go up; but great caution is necessary in adopting such a plan. In the treatment of strangulated hernia, we attempt first to replace the protruded parts; which operation is technically termed the taxis. The patient should lie down, with his pelvis placed higher than the shoulders, with the thigh, in inguinal and crural hernia, bent and rolled inwards; the bladder being previously emptied, and a caution being given to abstain from coughing, holding the breath, &c. Gentle, pressure must now be made on the tumour, and increased to a certain extent, but if possible, not so as to give pain. A general pressure may be made with both hands, or the tumour may be grasped with one, while the other is placed at the aperture, and employed in facilitating the entrance of the parts, or in keeping up those which have been already returned. The pressure should be exerted according to the course in which the parts have been protruded; i. e. upwards and outwards in the bubonocele, backwards and then upwards in the femoral hernia. Small herniæ are the most difficult of replacement; and the taxis succeeds also oftener in the early than the later periods of strangulation. It should not be persevered in when the rupture becomes painful. Mild purgatives and clysters should be used, even if the taxis succeeds. When we have not succeeded in replacing the parts, various means may be adopted in the treatment of a strangulated rupture. Those which are the most to be relied on are, bleeding, the warm bath, clysters of the decoction or smoke of tobacco, and ice, or other cold applications to the part. The former remedy must not be used indiscriminately, nor without a due attention to the patient's age and strength, nature of the symptoms, &c. Yet it should be employed with vigour when we have resolved on its use; and a considerable quantity should be drawn suddenly from a large orifice, to induce fainting. This, with the warm bath, and the employment of ice, or of the freezing mixtures, made by the solution of salts, are the means to be employed first; and if they fail, the tobacco clyster, made by boiling one drachm of tobacco for ten minutes in a pint of water, should be instantly tried. this does not succeed after two or three attempts, the operation must be performed without delay. A smart purge of calomel and jalap will sometimes succeed in the early stage of strangulation, partiVOL. XI. If cularly in old and large hernia, where disorder of the bowels may have been the cause of strangulation, and where the symptoms are not very urgent. Opium is of use to allay the sickness. The surgeon should act with the greatest decision in these cases, and should particularly avoid all unnecessary delay. He should try at once the most powerful means, and operate as soon as it is found that they will not succeed. Surgeons are now universally agreed, that the danger of the operation arises chiefly from its being deferred until the local or general disturbance have proceeded to such a height, that a favourable result can hardly be expected; and that the chance of recovery is very considerable, when it is performed under more favourable circumstances. We shall describe the operation in speaking of inguinal hernia. Inguinal hernia. The spermatic chord, in the male subject, and the round ligament of the uterus in the female, pass through a canal in the lower and front part of the abdominal muscles, called the abdominal ring. This canal is oblique in its course, commencing at the mid space between the spine of the ilium and angle of the pubes (upper or internal aperture,) running downwards and forwards, and terminating just over the pubes (lower or external aperture.) The upper opening is formed in a fascia, which ascends from Poupart's ligament, behind the abdominal muscles, and it is crossed above by the under edge of the internal, oblique, and transversalis muscles; the lower opening is formed by the tendon of the external oblique alone, and the distance between these is about two inches and a half. The inguinal hernia generally descends directly over the spermatic chord, which is consequently placed just behind the hernial sac; but it sometimes comes out directly from the abdomen, through the tendon of the external oblique, without traversing the canal of the abdominal ring; and here, consequently, the spermatic chord is an the outer side of the rupture. In the former and most frequent case, the epigastric artery runs along the inner edge of the mouth of the sac, while in the latter its course is on the outer side of the same part. The stricture may be situated, either at the upper or lower aperture of the ring, or in both. Besides the common symptoms belonging to all hernia, there are certain local characters which designate this species. The tumour descends from the abdominal ring to various distances in the Rr scrotum; appearing first in the groin, and passing downwards in front of the spermatic chord. The testicle may be felt below or behind the swelling, which always appears to extend into the ring, and is hence distinguished from most other affections of these parts. It is much more frequent in the male than in the female subject. It must be distinguished from hydrocele, varicocele, sarcocele, hernia, humoralis, and bubo. In operating for bubonocele, the patient's thigh should be bent, and the hair shaved from the swelling and neighbouring parts. An incision should be carried through the integuments, from an inch above the ring to the bottom of the tumour. The cellular substance intervening between the skin and hernial sac is then to be divided, layer by layer, with the knife and dissecting forceps; and the sac itself should then be opened with the edge of the knife held horizontally. A small portion of fluid is usually discharged at the aperture, which must be enlarged so as to expose the whole tumour.The stricture, in whatever part it may be situated, must now be divided by the probe-pointed knife, conducted by the finger or director, and carried directly upwards, so as to cut the middle of the upper part of the contracted portion. This incision, which is technically named the dilatation of the ring, should not be carried further than is absolutely neces sary for returning the parts. If the protruded parts are sound, and not adherent to each other, nor to the sac, they may be immediately replaced, the limb being always bent, and rolled inwards in this part of the operation, to relax the opening as much as possible. Intestine, although very much discoloured, will recover when placed in the cavity. If any adhesions exist, they must be destroyed by the knife, or finger, if they are not strong. The omentum is often found in a state in which it would be improper to return it. This viscus becomes thickened and hardened in an old hernia, so that its return would require a very free incision of the ring; and it is often discoloured by the inflammation consequent on the strangulation. In all such instances it should be cut away as far as it is affected, and the remainder returned into the abdomen, after any bleeding ves sels have been secured by fine ligatures. The practice of tying the omentum in a mass, previously to cutting it off, is very pernicious, and has often been fatal. The wound should be closed by a sticking plaster, assisted, if necessary, with one or two points of suture. Common clysters, and mild purgatives, such as manna and Epsom salts, dissolved in mint water, should be taken after the operation, and the strictest regimen observed until the recovery is complete. Peritoneal inflammation, which is not an unfrequent consequence, must be treated by the most vigorous antiphlogistic means; of which copious and repeated venesections are the most important. The operation above described would not be suitable in a case of large and old rupture. The extensive surface which must be exposed, and the violence necessary in separating adhesions, give rise to so much inflammation, that the consequences would be much dreaded; and the bulk of protruded parts has been sometimes so great, that they could not be retained in the belly after the operation. Here then the surgeon should take off the stricture without opening the sac, and push back as much of the contents as will pass up readily. When mortification has taken place in the contents of a rupture, our conduct must be adapted to the circumstances of the case. It is sometimes found to have occurred in the protruded parts, when no symptom had previously led the surgeon to suspect it. But the mortification generally spreads to the superincumbent parts; the swelling becomes soft; the integuments deep red, livid, and afterwards black; the cellular membrane is emphysematous; the pulse sinks; lastly, the integuments give way, and wind and feces are discharged. Although these cases are generally fatal, yet their event is sometimes fortunate. We must chiefly trust to nature, and be careful not to interrupt those processes which she employs for the restoration of parts. The intestine is adherent to the parietes of the abdomen behind the ring; these adhesions are of great importance in the subsequent progress of the cure, and should therefore never be disturbed. If the intestine has not already given way, we may remove the stricture: where an opening has taken place, we may make such incisions through the sphacelated parts as will provide a free exit for the fecal matter. In either case mild purgatives and clysters will be proper to unload the bowels, and to determine the course of the feces towards the anus. The use of both these means, with the latter object, constitutes a very important part of the treatment of all cases of mortified feces through the new opening, by supintestine. plying the patient with an apparatus, in which these may be received as they pass off. In cases where the mortification has not gone so far, the protruded gut may be affected either in one or more small spots; or it may have become mortified through a greater or less extent of its whole diameter. In the former case, it has been advised to leave the gut in the wound, after removing the stricture; or to return the intestine, and retain it in the neighbourhood of the ring by means of a ligature passed through the mesentery. The fear of an effusion of fecal matter into the abdomen, on the separation of the slough, formed the objection to the replacement of a mortified portion of gut; and the intent of the ligature placed in the mesentery was, to prevent the possibility of this much dreaded effusion, by keeping the sphacelated part opposite. to the ring. Since, however, numerous facts have shown that neither of these events are to be expected, there can be no doubt as to the conduct required, where a portion only of the gut is affected with gangrene. We should replace it in the cavity, with the mortified portion towards the wound, and await the result of the operations of nature without interference. When the whole diameter is mortified, the excision of the dead part, and the introduction of the upper into the lower end of the gut, where it is to be secured by ligature, has been advised. We have also been recommended to keep the two ends near the ring, by ligatures in the mesentery. We advise, that after dilating the stricture, the subsequent progress of the case should be left entirely to nature. The sloughs will be cast off; the ends of the gut are retained by the adhesive process, in a state of apposition to each other, the most favourable for their union; the wound contracts, and often completely closes, so that the continuity of the alimentary canal is perfectly reestablished. The interference of art can only be prejudicial in this process. Perhaps the only step which would be justifiable, is that of making an incision in the sphacelated part; this will promote the evacuation of the alimentary canal, and afford considerable relief. In all cases of mortified intestine there is considerable danger of the feces passing off constantly through the wound, by what is called an artificial anus. Here we must endeavour to alleviate those distressing inconveniences which arise from the involuntary discharge of wind and Femoral hernia is formed by the protrusion of some of the abdominal contents under the inferior margin of the external oblique muscle (which part is called also Poupart's ligament): and the swelling is situated towards the inner part of the bend of the thigh. It is much the most frequent in women, and is generally very small; hence it may be mistaken for a swollen gland, unless great attention be paid to the symptoms. The precise point at which this hernia descends is the space left under the crural arch, between the femoral vein and the thin posterior edge of Poupart's ligament. The latter part has a broad insertion into the pubes, and this insertion ends in a thin and very sharp margin, turned towards the vein. The contents of the abdomen cannot escape in any other situation, because the crural arch is filled by parts going under it, and covered by a fascia extending over the iliacus internus muscle. The rupture first descends, and then comes forwards, to which we must attend in endeavouring to reduce it. The peritoneal sac is covered by a very complete exterior investment, as in the inguinal species. The spermatic chord, or round ligament, passes directly over the mouth of the sac, and the epigastric lies on its outer edge. The stricture, which is always very close, should be relieved, by detaching the thin edge of Poupart's ligament from the pubes. Umbilical hernia, exomphalos, or omphalocele, is formed by the protrusion of the viscera through the tendinous opening termed the navel. An elastic truss for this rupture is described by Mr. Hey, and is the best hitherto contrived. There is nothing peculiar in the treatment or operation, nor in those of the ventral and congenital kinds. The surgeon, however, in the latter, will be aware that the hernial contents lie in the same bag with the testis, in consequence of the communication that exists in one period of the fetal existence between the abdomen and tunica vaginalis testis never having been closed. Hence, in such a case the testis cannot be felt distinctly from the hernial swelling. Hydrocele is a collection of watery fluid in the cavity of the tunica vaginalis testis, or in the spermatic chord. The former is exactly similar in its nature to the dropsical affections of the peritoneum, pleura, or pericardium. The swelling is colourless, smooth, and pyriform; extending slowly and gradually upwards from the lower part of the scrotum; fluctuating, and incapable of reduction or diminution; often there is a degree of transparency, so that the light can be discerned through it; but as the tunica vaginalis is frequently thickened, neither this circumstance, nor the fluctuation, can be entirely depended on. The testis cannot be felt, but the spermatic chord may be discerned clearly, in a natural state, above the swelling. The cure is either radical, or palliative: the latter consists in letting out the fluid with a trochar, after which a piece of soap plaster may be applied, and a bag-truss worn. The fluid accumulates again. In the radical cure, the hydrocele should be tapped with a trochar at its anterior and inferior part, and as soon as the fluid is entirely discharged, the cavity of the tunica vagi nalis is to be distended to its former dimensions, with an injection composed of two parts of red wine, and one of warm water. The injection may remain in the part about five minutes, after which it is to be discharged through the trochar. The consequence of this treatment is a considerable inflammation of the part, terminating in the effusion of coagulating lymph, and the consequent obliteration of the cavity of the tunica vaginalis. The inflammation is to be treated like hernia humoralis, if it runs too high. Hydrocele of the chord may either consist of an effusion of water into the cellular substance, or of a single cyst of various magnitude. If the former prove troublesome, a free incision through it seems to be the only means of treatment; the latter may be treated by the port wine injection. Hamatocele is a swelling of the scrotum, caused by the effusion of blood into the tunica vaginalis. Its most common cause is the wound of a blood-vessel in tapping_a_hydrocele: the water, as it flows off, is generally discoloured, and the swelling soon after regains its former magnitude. Discutient lotions, as that of the sal ammoniac, or cerussa acetata and vinegar, will generally cause the absorp. tion of the blood; camphorated liniments and mercurial ointment may also be employed, if the case be obstinate. Should these means fail entirely, an incision must be made through the integuments and tunica vaginalis, and the blood removed. Sarcocele is a chronic fleshy enlarge. ment of the testicle. It exhibits very different appearances in different cases. It may present a vascular mass of uniform appearance, without enlargement of the chord, or any very painful symptoms. It may have a white caseous substance intermixed with this; or it may contain several cells, filled with different coloured fluids. But it is also liable to scirrhus and cancer; in which case it forms a hard brownish mass, with portions of a membranous or gristly firmness intermixed; attended with severe pain darting along the chords to the loins; and having an unequal knotty feel. The chord too becomes enlarged, and the health is affected. Sometimes this kind of sarcocele forms a foul ulcer, with bleeding tungus, &c. When the chord is affected the disease generally appears in the inguinal glands, and soon after destroys the patient. A mild sarcocele may be treated with leeches and discutient lotions, setons, and mercurial frictions, with the view of dispersion; but if these fail, castration is the only remedy The same means should be immediately employed in a case of scirrhus; for that affords no hope of cure. The operation would also be too late, if deferred until the chord has become indurated and knotty. Chronic enlargements of the testicle are sometimes attended with an accumulation of limpid fluid in the tunica vaginalis; and the disease is then termed hydro-sarcocele. The operation of castration consists in making a longitudinal incision from the abdominal ring to the bottom of the tumour; in dissecting down each side of the spermatic chord, so as to be able to take it between the finger and thumb; in dividing the chord, and tying any bleeding vessels on its surface; and then in dissecting away the testis, by free sweeps of the knife, from the scrotum. All bleeding vessels should be carefully secured; the edges of the integuments retained by two or three points of suture, and in their intervals by sticking plaster; bandage, are to be applied. over which a pledget, compress, and T Varicocele is an enlargement of the veins of the scrotum, or spermatic chord, attended with a very peculiar feel, and causing a tumour, which is generally indolent, but may be troublesome. It is often mistaken for omental hernia; and sometimes is attended with wasting of the testicle. If the swelling be painful, leeches, saturnine and discutient lotions, purgative medicines, horizontal position, |