SURGERY. 
signs of approaching strangulation are the 
following; pain in the tumour, an unusual 
uneasy sensation ovef the whole belly, in- 
creased by any exertion of the abdominal 
muscles, costiveness, quick and hard pulse, 
nausea, vomiting, an increase and extension 
of the pain, greater tenseness in the abdomen, 
extreme anxiety, and other symptoms oi pe- 
ritoneal inflammation. 
These symptoms demand speedy remedies; 
when the’mflainmatioir and pain are already 
too violent to admit of attempts to reduce the 
rupture, they should be, ifpossible, subdued by 
fomentations over the tumour, and the whole 
of the abdomen, by the injection or clysters, 
by warm bathing, and by topical and general 
blood-letting. The return of the bowels 
should as soon as possible be attempted, for 
inflammation may have been present for some 
time without so much of stricture on the ring 
having been induced as to prevent reduction, 
if properly reguated. The patient should 
be placed on the side opposite the hernia, 
with his pelvis and lower limbs raised, in order 
to relax the muscles; the tumour is thereto be 
grasped, and pressure made with the fingers 
in a direction upwards, and a little inwards 
towards the crural arch, if the hernia be of 
the thigh; upwards, and outwards towards the 
ring, if it bean inguinal or scrotal hernia. 
When the inflammatory symptoms con- 
tinue, the tumour is incapable of reduction, 
and every appearance proves a complete 
strangulation of the hernial sac ; there is no 
safety for the patient, unless in the operation 
which we are now briefly to describe for the 
inguinal and femoral hernia, which are the 
principal , and almost only cases of strangulat- 
ed hernia lor which the surgeon is called 
upon to operate. 
Operations for inguinal or scrotal her- 
nia;. The patient should be laid with his 
body in an almost horizontal position ; while 
the buttocks are somew hat elevated, the thighs 
are to be raised, and secured by assistants; the 
parts are first to be shaved, an vneision is then 
to be made with a scalpel through the skin 
and cellular texture, commencing about an 
inch above the tumour, and carrying it down 
some way below the abdominal ring ; the ring 
being thus exposed, a directory is to be in- 
troduced between it and the .sac, in a direc- 
tion upwards and outwards. A blunt pointed 
bistuory is to be inserted in the groove of the 
directory, and the ring dilated by this instru- 
ment till the point of the linger can be intro- 
duced; while the surgeon makes the dila- 
tation of the ring sufficient to reduce the 
hernia, he must be careful of not dilat- 
ing too freely, lest the bowels be again 
forced down. The stricture being thus re- 
lieved, the protruding intestines are to be re- 
turned, the outer wound closed with stitches, 
and proper bandages applied. When the 
wound has cicatrized, a truss should be 
worn. 
The operation for femoral herniie is per- 
formed much in the same manner. Here the 
stricture is from the ligament of the thigh, 
which, after the sac has been opened, is to be 
divided to the requisite extent. 
Hydrocele . Hydrocele, or dropsy of the 
scrotum, is either encysted or anasarcous ; 
either diffused thro'ngd the cellular mem- 
brane, or contained in the tunica vaginalis. 
The anasarcous hydrocele is distinguished 
from the encysted by the general spreading 
of the tumour, by its comparatively rapid 
progress ; and although it sometimes depends 
.upon a topical cause, by its being more usu- 
ally connected with general dropsy. Anas- 
arcous hydrocele is treated by scarifications, 
or punctures; but unless the dropsical ten- 
dency be counteracted by general remedies, 
much advantage is not to be expected from 
either. 
Hydrocele of the vaginal coat generally 
first comes on with a sense of fulness about 
the inferior part of the testicle, which gra- 
dually becomes more tense, and rises higher 
in the body of the testicle: the increase of the 
swelling sometimes occasions the penis almost 
to disappear. The tumour throughout is 
scarcely attended with any pain ; it is usually, 
but not invariably, transparent; its trans- 
parency and fluctuating feel, indeed, have 
been made a criterion to distinguish this 
from scrotal hernia ; but such distinction is 
formed with more accuracy by the manner in 
which the disorder has commenced and pro- 
ceeded, viz. from below, upwards ; (the con- 
trary is the case with hernia:) and by no de- 
gree of pressure making the swelling to dis- 
appear. 
The tunica vaginalis may be punctured, 
and the water drawn off as in other species 
of dropsy; but this operation affords only a 
temporary, not a radical cure. The radical 
treatment consists in not merely evacuating 
the water from, but causing an irritation be- 
tween the vaginal and albugineous coats of 
the testicle, to make them adhere, and thus 
obliterate the cavity. This is effected by in- 
cision, by caustic, or by injection; the last 
of which, recommended by Mr. Earle, is 
now, on account of its mildness, ancl safety, 
very generally practised. The water is first 
drawn off by a trocar passed into the under 
and fore part of the tumour; the canula of 
which is still left in the orifice, the operator 
securing it with one hand, passes the tube of 
; an elastic bag (filled with red wine somewhat 
diluted) directly through the canula; lie then 
injects the contents of the hag into the cavity, 
leaves the tube of the instrument, which is 
provided with a stop-cock, in the canula, by 
which the injected fluid is retained. This, 
after remaining about five or six minutes, is to 
be taken out, and the fluid suffered to dis- 
charge itself through the canula. 
The wound in the testicle is now to be co- 
vered with a pledgit of lint ; the testicle it- 
self is to be supported in a suspensary band- 
age, and the patient confined to his bed 
for some days. After this method of treat- 
ment, hydrocele is apt to return, but the ope- 
ration can then be repeated. 
The spermatic cord is subject to hydro- 
cele, both of the anasarcous and encysted 
kind. The latter is sometimes confounded 
with hernia, but may be distinguished from 
it by thetumour commencing at some distance 
down the cord, though it is stiff above the 
testicle, which is not the case in the hydrocele 
of the tunica vaginalis. This swelling may 
likewise be distinguished from hernia; by its 
not being altered in size from any posture or 
pressure. When the tumour becomes large, 
the palliative, or radical cure, as in the va- 
ginal hydrocele, must be resorted to. 
Varicocele is an unusual distension of the 
scrotal veins. Circocele, the same affection 
of the spermatic cord. Spermatocele is a 
disordered distension of the vas deferens and 
751 
epidydimis, Rheunratacele is a distension of 
the scrotum from a collection of air. 
These several affections arise from local 
or constitutional derangements, by remedying 
which they are relieved or cured. 
Sarcocele is a schirrous enlargement oi the 
testicle, like other cancerous affections (lor 
this disorder, sooner or later, commonly tern 
minutes in open ulcer), it is sometimes’ pro- 
duced by obvious causes, at others it toiu- 
mences imperceptibly. Sometimes it re- 
mains in a schirrous state for a long time ; at 
others, especially when the subject of tide 
disorder is advanced in years, it soon break's 
out into open cancer. 
When for tins affection it becomes nect-- 
sary to extirpate the testicle, the operation is 
to be performed by making first an incision 
some way above the abdominal rings, which 
is to be carried through the adipose mem- 
brane to the bottom of the scrotum. A firm 
waxed ligature is to be passed round the sper- 
matic cord, near the ring ; the vessels are then 
to he tied by a running knot, and divided at 
a little distance below the ligature. The 
testicle and cord are to be removed bv dis- 
secting from above downwards, with the’ com- 
mon scalpel. The spermatic arteries and 
veins are then to be taken up with the temi- 
culum, and ligatures passed round them ; the 
ligature round the body of the cord being 
slackened, the edges of the wound are roe to 
be brought as accurately together as possible, 
and secured by adhesive plaster, leaving the 
ligatures hanging out of the wound. The 
compress of linen and a T bandage are to be 
applied over the whole. 
Inflammation is to be as much as possible 
prevented by keeping the dressings moisten- 
ed with a saturnine lotion, but the wound is- 
not to be examined until about four or five 
days from the operation.. 
Of stone in the bladder.. 
A disposition to calculary concretions very 
often displays itself in early life. Large stones 
have been extracted from the bladder of very 
young subjects. Most commonly* however, 
life has considerably advanced before these 
concretions form at least to any perceptible 
extent, either in the kidneys or in the blad- 
der. The symptoms of stone are irregular. 
One of the first sensations is often an uneasi- 
ness referred to the point of the urethra 
which is more observable during the passage 
of the urine. This sensation appears in & a 
manner to increase the desire to make water, 
which is often discharged with difficulty, and 
only by drops. Sometimes a constant' dull 
pain is experienced in the region of the pubis: 
at oilier times the pain is more severe, and 
not continued. Exercise, especially ridin«- 
on horseback, increases the symptoms. When 
the calculus is secreted in the kidneys, pain 
is felt in the Joins, which frequently passes 
along towards the bladder. Such ’are the 
symptoms by which the existence of stone 
may be without much hesitation decided’ 
upon. When small concretions are thrown 
out of tiie bladder with the urine, the nature 
of the complaint is of course unequivocal. 
When there is room for doubt, a sound: 
(fig. 50) is to be introduced into the bladder. 
This instrument, previously to its introduc- 
tion, should be moistened with oil. The- 
suigeoo is to lay hold of the penij with hi^ 
