SURGERY. 
ed, if necessary, ■with one or two points of 
suture. Common clysters, and mild pursa- 
tive.«, such as manna and Epsom salts, dis- 
solved in mint water, should be taken after 
the operation, and the strictest regimen ob- 
served until the recovery is complete. Pe- 
ritoneal inflammation, which is not an un- 
frequent consequence, must be treated by 
the most vigorous antiphlogistic means; ot 
which copious and repeated venesections 
are the most important. 
The operation above described would not 
be. suitable in a case of large and old rup- 
ture. The extensive snrfiice which must 
be exposed, and the violence necessary in 
sepai'ating adhesions, give rise to so much 
inflammation, that the consequences would 
be much dreaded ; and the bulk of pro- 
truded 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 open- 
ing 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 sympton had 
previously led the surgeon to suspect it. 
But the mortification generally spreads to 
the superincumbent parts : the swelling be- 
comes soft; the integuments deep red, livid, 
and afterwards black ; the cellular mem- 
brane 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 natqre, and be careful not to inter- 
rupt those processes which she employs for 
the restoration of parts. The intestine is 
adherent to the parietes of the abdomen be- 
hind the ring ; these adhesions are of great 
importance in the subsequent progress of 
the cure, and should therefore never be dis- 
turbed. 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 deterpiine 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 intestine. 
In cases where the mortification has not 
gone so far, the protruded gut may be af- 
fected 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 fe- 
cal matter into the abdomen, on the separa- 
tion of the slough, formed the objection to 
the replacement of a mortified portion of 
gut : and the intent of the ligature placed 
in tlie mesentery was to prevent the possi- 
bility 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 
slionld replace it in the cavity wjth the mor- 
tified portion towards the wound, and aw'ait 
the result of the operations of nature with- 
out interference. 
AVhen the whole diameter has mortified, 
the excision of the dead part, and the intro- 
duction of the upper into tlie lower end of 
the gut, where it is to be secured by liga- 
ture, has been advised. , We have also been 
recommended to keep the two ends near the 
ring, by ligatures in the mesentery. We ad- 
vise, 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 appo- 
sition to each other, the most favourable 
for their union ; the wound contracts, and 
often completely closes, so that the con- 
tinuity of the alimentary canal is perfectly 
re established. The interference of art can 
only be prejudicial in this process. Perhaps 
the only step which would be justifiahio, is 
that of making an incision in the sphacelat- 
ed part; this will promote tlie evacuation 
of the alimentary canal, and afford consider- 
able 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 en- 
deavour tp alleviate those distressing incon- 
veniences which arise from the involuntary 
discharge of wind and feces through the 
new opening, by supplying the patient with 
an apparatus, in which these may be re- 
ceived as they pass off. 
