SURGERY. 
many hours, and have recovered after the operation for 
strangulated hernia. After the appearance of hiccough, you 
may prevent gangrene by bleeding, and using other means 
for reducing the patient. The hiccough will sometimes re¬ 
main for several days after the operation, and in this case 
bleeding will relieve the patient more than any thing else. 
When gangrene has actually taken place, the patient will 
tell you that he has got rid of all his pain, and that he feels 
a great deal better; but if you put your hand on his abdo¬ 
men, you will find it still tense and tender; his pulse will 
be intermitting, small, and irregular, and the swelling will 
feel tense and somewhat emphysematous. In this state it 
sometimes happens that the hernia, by a little pressure, may 
be returned into the abdomen, in consequence of the great 
relaxation of the surrounding parts from the effects of gan¬ 
grene. Death, however, is close at hand.” 
Clearly as these symptoms are detailed, and accurately as 
they correspond with what is in the majority of cases 
observed, the student must not expect to find them invari¬ 
able. There are some cases, especially in very old persons, 
in whom the marked tenderness of the abdomen as well as 
its tenseness and inflation are not very obvious. A frequent 
hard pulse, nausea, anxiety and constipation, are, in a few 
rare instances, the only symptoms, and the cases are more 
numerous in which the symptoms, though severer, are yet 
by no means equal to those so well noted by Sir Astley as 
usual in this complaint. Exomphalos especially, the most 
dangerous to life, has the mildest symptoms. 
When a man applies to a surgeon with strangulated her¬ 
nia, the course pursued should be as follows:—In the first 
place, he should endeavour, by means of the hand, very 
gently and carefully, to return the intestine. If this does 
not succeed, he should neither practice nor allow any more 
handling, but immediately use constitutional remedies. His 
attention ought to be directed fo making the patient faint as 
fast as possible. For this purpose a very large bleeding 
should be made, and the patient immediately placed in a 
warm bath. The endeavour to return the bowel may now 
be made. If faintness be perfectly induced, and yet this 
attempt does not succeed, it is of no use to do any thing 
more, and the sooner the operation is performed the better. 
But if faintness has not been induced, other means are some¬ 
times had recourse to, such as the tobacco enema. There is 
a difference of opinion among surgeons as to the use of this 
remedy, but there seems no reasonable objection to its use, 
except one which applies to every thing else, viz., that too 
much time may be lost in its application. 
The measures above mentioned being found unsuccessful, 
an operation for the relief of the intestine is at once to be 
decided on. With respect to the time that may be suffered 
to elapse, between the occurrence of the strangulation and 
the performance of the operation, this is various. It is gene¬ 
rally allowed, that most patients die because the operation 
is performed too late. With respect to young patients, those 
who have small or recent hernia, there is no occasion to wait 
an instant. Inflammation, is in these cases, going on ra¬ 
pidly ; the constitutional means have been tried, (and these, 
if not successful when suddenly put in force, cannot be 
successful when more tardily used); the disease has never 
the slightest tendency to a spontaneous cure: then, why 
delay the operation and keep the patient in suspense at all ? 
In old patients, in those who have large and ancient hernia, 
we may wait for some time without danger; but even here 
we can expect no advantage from waiting, that is, if we are 
perfectly convinced strangulation exists. But old persons, 
with large hernise, are subject to an obstruction in the intes¬ 
tines, which the French call engouement, and which arises 
from a quantity of foetid matter distending preternaturally 
the intestine, so that it cannot return into the belly. These 
cases are generally to be cured by the application of pounded 
ice to the swelling, and the exhibition of brisk purgatives 
and emetics. 
The operation for hernia varies, of course, with the na¬ 
ture of the complaint: we shall first describe the operation 
for common inguinal hernia. The external incision should 
Voi~ XXIII. No. 1603. 
725 
begin an inch above the outer angle of the ring, and extend 
over the middle of the tumour to its lower part. Either by 
this first incision, or in the subsequent dissection down to 
the sac, the external pudic branch of the femoral artery may 
be divided, and ought to be tied when the hemorrhage from 
it is profuse. After thus dividing the skin, the cellular sub¬ 
stance lying upon the outside of the hernial sac is to be 
raised with a pair of dissecting forceps and cautiously cut, 
layer by layer. In order to lessen the risk of cutting sud¬ 
denly through the sac and wounding the bowels, the sur¬ 
geon should not only elevate the layers of cellular substance 
with (he forceps, but take care to divide them with the edge 
of the knife inclined rather horizontally. The opening 
into the sac can be accomplished with most security at the 
lower part of the tumour, because fluid is sometimes con¬ 
tained in the sac, and, in that case, always gravitates to the 
bottom of the swelling. An opening having been made, 
it is to be enlarged in both directions with the probe-pointed 
bistoury, guided by the finger or director until the whole 
cavity is laid open. The presence of fluid is not a constant 
circumstance, and, therefore, cannot be depended upon as a 
criterion, which will always serve for shewing when the first 
aperture is made in the hernial sac. The circular arrange¬ 
ment of the arteries of the intestine, and its very smooth 
surface distinguish it from the hernial sac, which is rather 
rough and cellular on its surface, and is in general closely 
connected with the surrounding parts. Since the spermatic 
vessels are apt sometimes to deviate from their ordinary 
situation, in respect to the hernia, and lie more or less in 
front of the sac, every operator ought to endeavour to ascer¬ 
tain such variations, if possible, before hand, in order that 
he may avoid parts which should never be injured. When 
the hernial sac has been in this manner opened, and its con¬ 
tents fairly brought into view, the next object is to liberate 
them from the state of stricture in which they are. “ The 
finger should be carried as far into the neck of the sac as it 
can be without violence, and between the protruded parts 
and the upper margin of the stricture. The bistoury, with 
its back resting on the finger, is pushed forwards towards 
the abdomen, followed and supported by the finger which 
protects the viscera. The length of the incision should not 
exceed what is sufficient to allow the viscera to be replaced 
with ease.” Lawrence .-—The direction of this should be, 
in every case, i. e. whether the hernia be direct or oblique, 
directly upwards. 
The last thing which the surgeon has to achieve in the 
operation, is to reduce the viscera into the cavity of the 
abdomen, a circumstance, which may be directly done,- 
when the protruded parts are sound and free from adhesions. 
When the bowel is mortified, which is known by its being 
tesselated with green spots, it is useless to return it; it 
must be cut off, and an artificial anus formed, as in cases of 
mortification of the intestines from ordinary wounds. Ad¬ 
hesions, when recent and slight, may be divided with the 
finger, when old by a cautious use of the knife. The 
omentum, when redundant or mortified, may be removed, 
and any bleeding arteries in its substance secured by liga¬ 
tures. 
In the operation for femoral hernia, “ the first incision ex¬ 
poses the superficial fascia, which is given off by the external 
oblique muscle, and which covers the anterior part of the 
hernial sac; but if the patient is thin, and the hernia has not 
been long formed, this facia escapes observation, as it is then 
slight and delicate, and adheres closely to the inner side of 
the skin. When this facia is divided, the tumour is so far 
exposed, that the circumscribed form of the hernia may be 
distinctly seen. It is still, however, enveloped by a mem¬ 
brane, which is the fascia, that the hernial sac pushes before 
it, as it passes through the inner side of the crural sheath. 
This membrane, the fascia propria, is to be next divided 
longitudinally from the neck to the fundus of the sac ; and 
if the subject is fat, an adipose membrane lies between it and 
the sac, from which it may be distinguished by seeing the 
cellular membrane passing from its inner side to the surface 
of the sac. 
8 Y 
“ The 
