7 26 
SURGERY. 
“ The hernial sac, being exposed, is to be next opened ; 
and, to divide it with safety, it is best to pinch up a small 
part of it between the finger and the thumb; to move the 
thumb upon the finger, by which the intestine is distinctly 
felt, and may be separated from the inner side of the sac; 
and then to cut into -the sac, by placing the blade of the 
knife horizontally. Into this opening a director should be 
passed, and the sac opened from its fundus to the crural 
sheath.” See A. Cooper on Crural and Umbilical Hernia. 
The incision of Gimbernat’s ligament should now be made, 
and the operation completed. 
The treatment of a congenital inguinal hernia is to be 
conducted on the same general principles as apply to other 
ruptures. After the viscera are reduced, the communica¬ 
tion between the abdomen and scrotum may, by the regular 
and uninterrupted use of a well-made truss, be obliterated. 
If the patient be young, this cure may be completed in the 
course of a few weeks. But if a piece of intestine, or omen¬ 
tum, gets low down in the sac, while the testis is in the 
abdomen, the application of a truss would be highly im¬ 
proper; except, however, when a hernia takes place in a 
patient whose testis has not descended, and whose age makes 
it doubtful whether it ever will descend. 
In the operation, the surgeon should remember, that the 
testis will often be found between the intestine and omentum; 
that, after their reduction, it will be left quite bare in the ex¬ 
posed cavity of the sac; and that, as it is a part very sensible 
and prone to inflammation, it should never be unnecessarily 
handled and disturbed. 
The sac of a congenital rupture is frequently very thin ; 
sometimes firmly adherent to the skin, at others to the testis, 
often subject to that kind of strangulation which is caused 
by the neck of the hernial sac, and liable to various con¬ 
tractions in the course of the sac which require dilatation. 
Besides the preceding ruptures, there are several others of 
various kinds; which, though unfrequent, are deserving of 
notice. These are,— 
1. Ventral herniae.—'The term •central is extended to all 
such ruptures as happen at any other parts of the abdomen 
besides the abdominal ring, under the crural arch, and at 
the navel. 
In certain instances, these eventrations are the consequence 
of repeated pregnancies. In this way, the fore-part of the 
abdomen has been observed to be so completely weakened 
(the effect of reiterated distention), as to form a bag, which 
descended over the thighs, and contained not only the 
omentum and mass of intestines, but even the gravid uterus 
itself. See what we have said under exomphalos. 
Eventrations can hardly become strangulated, though bad 
and fatal symptoms may be occasioned by an accumulation 
of intestinal matter, and by obstruction in some part of the 
protruded viscera. 
2. Hernia of the bladder, or cystocele.—A hernia of this 
kind differs materially from ordinary cases, since there is no 
hernial sac, and the disease rather consists of an elongation, 
than a displacement of the bladder. The impossibility of a 
complete displacement must, indeed, be immediately obvious, 
on reflecting how firmly this organ is fixed to the perineum 
and os pubis. 
When, in a person subject to retentions of urine, the 
bladder is much dilated, rising above the pubes, it acquires 
a situation behind the abdominal ring, without any inter¬ 
position of the peritoneum. In this state, the least effort may 
bring on an elongation of the distended bladder through 
that opening. Thus, a kind of appendage to this organ is 
formed, which may reach more or less downwards. In 
most instances it descends no lower than the groin; occa¬ 
sionally it passes into the scrotum. When a considerable 
portion of the urinary bladder is protruded, its fundus and 
posterior surface are dragged towards the ring, and even pass 
through this aperture, together with the peritoneum, which 
covers them. 
The portion of this membrane, which is thus drawn out by 
the protruded part of the bladder, and follows it, composes a 
pouch, into which the omentum and bowels escape, so that 
a cystocele is very commonly complicated with an ordinary 
inguinal hernia. 
A hernia of the bladder is characterized by a soft, oblong, 
fluctuating tumour, situated in the bend of the groin ; it 
makes its first appearance near the abdominal ring, and gra¬ 
dually increases in size by descending more and more to¬ 
wards the scrotum. The swelling is made to disappear by 
compression; it becomes larger when the patient holds his 
water; but diminishes and entirely subsides when he makes 
such evacuation. The last circumstance unequivocally dis¬ 
tinguishes the disease from the encysted hydrocele of the 
spermatic cord, while the feel of fluctuation exhibits its dif¬ 
ference from an enterocele. It is also to be remembered that 
cystocele seldom afflicts persons unless they have been often 
troubled with retentions of urine. The patient in general 
makes water more frequently than natural. 
Besides this sort of hernia of the bladder, there are cases 
on record, where portions of this viscus have been pro¬ 
truded under the crural arch, and in the perineum and 
vagina. 
Were a surgeon called to a cystocele in a very recent state, 
he should endeavour to reduce the protruded part, and keep 
it up with a truss. In almost all cases, however, the case is 
irreducible, in consequence of the prolapsed part being firmly 
adherent in its unnatural position. 
3. Perineal hernia.—The records of surgery furnish us 
with examples of hernia:, which have occurred at the lower 
aperture of the pelvis. In men, the viscera are protruded 
between the bladder and rectum; in women, between the 
rectum and vagina. As the part, where the peritoneum is 
reflected from the rectum to the vagina, or bladder, is at a 
considerable distance from the peritoneum, it is not difficult 
to comprehend, that a protrusion may exist, without forming 
any external swelling. When this is the case, the hernia 
can only be distinguished in men by examining within the 
rectum; in women, the disease may be detected both in this 
way, and by feeling within the vagina. 
4. Hernia of the vagina.—The situation in which the pro¬ 
trusion begins is the same as in the perineal rupture; but in 
the latter case, the vagina resists, and does not give way. In 
the rupture now under consideration, the swelling projects 
into the vagina,, and is covered by the membrane of that 
canal. Women who have borne children, are more subject 
to this disease than other females. The tumour is mostly 
formed by the small intestines. When the protrusion is 
occasioned by the bladder, the swelling is situated on the 
anterior and upper surface of the vagina. This species of 
hernia is generally brought on by a violent exertion. Its 
contents may be readily pushed up by the hand, but they 
descend again if the patient coughs or strains. All active 
and laborious pursuits are productive of a painful sense of 
bearing down. The disease is frequently accompanied with 
disorders of the alimentary canal. Very often the bladder 
is affected, in consequence of the vicinity of the tumour. 
When this receptacle itself forms the protrusion, pressure on 
the swelling will cause a discharge of urine from the meatus 
urinarius. 
In this disease, the first indication is to reduce the parts by 
the pressure of the hand, care being taken to effect a com¬ 
plete reduction, and not allow any portion of the protruded 
viscera to continue in the long track, through which they 
may have descended. Therefore they must be pressed up as 
far as the os uteri. They are to be prevented from descend¬ 
ing again by the use of a pessary, which must be shaped 
either like a globe, or hollow cylinder. 
The vaginal hernia might be attended with much danger 
and inconvenience, were it to be down at the time of partu¬ 
rition. Hence, during the labour pains, it behoves the prac¬ 
titioner to maintain the viscera reduced by pressure, until the 
child's head has passed down into the pelvis. Should the 
head have descended, while the rupture is down, delivery 
should be expedited as much as possible. 
There is an operation which surgeons are occasionally 
called on to perform, called Paracentesis Abdominis. This 
operation consists in plunging a trocar into the cavity of the 
peritoneum. 
