Ins-lanai hernia. The spermatic chord, in the male subject, and the round liga ment 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 an gle of the pubes (upper or internal aper ture,) running downwards and forwards, and terminating just over the pubes (low es or external aperture.) The upper opening is formed in a fascia, which as cends from Poupart's ligament, behind the abdominal muscles, and it is crossed above by the under edge of the internal, oblique, and transeersalis muscles; the lower opening is formed by the tendon of the external oblique alone, and the dis tance between these is about two inches and a half. The inguinal hernia gene. rally 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 ob lique, without traversing the canal of the abdominal ring; and here, consequently, the spermatic chord is ma 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 stric ture may be situated, either at the upper or lower aperture of the ring, or in both.
Besides the common symptoms be longing to all hernia:, there are certain local characters which designate this spe cies. The tumour descends from the ab dominal rine to various distances in the scrotum ; appearing first in the groin, and passing downwards in front of the spermatic cbord. 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 distin guished from hydrocele, varicocele, sar cocele, hernia, humoralis, and bubo.
In operating for bubonocele, the pa. tient's thigh should be bent, and the hair shaved from the swelling and neighbour ing parts. An incision should be carried through the integuments, from an inch above the ring to the bottom of the tu mour. The cellular substance interven ing 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 discharg ed at the aperture, which must be enlarg ed 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 pro truded 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 open. ing as much as possible. Intestine, al
though very much discoloured, will reco ver 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 thicken ed and hardened in an old hernia, :in that its return would require a very free in cision of the ring; and it is often disco loured by the inflammation consequent on the strangulation. In all such instan ces 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 clys ters, 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 inflam mation, which is not an unfrequent con sequence, 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 ne cessary in separating adhesions, give rise to so much inflammation, that the conse quences 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 opera tion. 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 ge nerally spreads to the superincumbent parts ; the swelling becomes soft ; the integuments deep red, livid, and after wards 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 in terrupt those processes which she em ploys for the restoration of parts. The intestine is adherent to the parietes of the abdomen behind the ring; these ad hesions 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 pur gatives 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 intestine.