In cases where the mortification has not gone so far, the protruded gut may be affected 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 mesen tery. The fear of an effusion of fecal matter into the abdomen, on the separa tion of the slough, formed the objection to the replacement of a mortified por tion of gut ; and the intent of the liga ture placed in the mesentery was, to pre vent the possibility 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 re quired, where a portion only of the gut is affected with gangrene. We should replace it in the cavity, with the mortifi ed portion towards the wound, and await the result of the operations of nature with out interference.
When the whole diameter is mortifi ed, the excision of the dead part, and the introduction of the upper into the lower end of the gut, where It is to be secured by ligature, has been advised. We have also been recommended to keep the two ends near the ring, by ligatures in the mesentery. We advise, 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 pro cess, in a state of apposition to each other, the most favourable for their union ; the wound contracts, and often completely closes, so that the continuity of the alimentary canal is perfectly re established. The interference of art can only be prejudicial in this process. Per haps the only step which would be justi fiable, is that of making an incision in the sphacelated part ; this will promote the evacuation of the alimentary canal, and afford considerable relief.
In all cases of mortified intestine there is considerable danger of the feces pass ing off constantly through the wound, by what is called an artificial anus. Here we must endeavour to alleviate those dis tressing inconveniences which arise from the involuntary discharge of wind and feces through the new opening, by sup. plying the patient with an apparatus, in which these may be received as they pass off.
Femoral hernia is formed by the pro trusion of some of the abdominal contents under the inferior margin of the external oblique muscle (which part is called also Poupart's ligament): and the swelling is situated towards the inner part of the bend of the thigh. It is much the most frequent in women, and is generally very small; hence it may be mistaken for a swollen gland, unless great attention be paid to the symptoms. The precise point at which this hernia descends is the space left under the crural arch, between the femoral vein and the thin posterior edge of Poupart's ligament. The latter part has a broad insertion into the pubes, and this insertion ends in a thin and very sharp margin, turned towards the vein.
The contents of the abdomen cannot es cape in any other situation, because the crural arch is filled by parts going under it, and covered by a fascia extending over the iliacus internus muscle. The rupture first descends, and then comes forwards, to which we must attend in endeavour ing to reduce it. The peritoneal sac is covered by a very complete exterior in vestment, as in the inguinal species. The spermatic chord, or round ligament, passes directly over the mouth of the sac, and the epigastric lies on its outer edge. The stricture, which is always very close, should be relieved, by detaching the thin edge of Poupart's ligament from the pubes.
Umbilical hernia, exomphalos, or om phalocele, is formed by the protrusion of the viscera through the tendinous open ing termed the navel. An elastic truss for this rupture is described by Mr. Hey, and is the best hitherto contrived.
There is nothing peculiar in the treat ment or operation, nor in those of the ventral and congenital kinds. The sur geon, however, in the latter, will be aware that the hernial contents lie in the same bag with the testis, in consequence of the communication that exists in one period of the fetal existence between the abdo men and tunics vaginalis testis never hav ing been closed. Hence, in such a case the testis cannot be felt distinctly from the hernial swelling.
Hydrocele is a collection of watery fluid in the cavity of the tunics vaginalis testis, or in the spermatic chord. The former is exactly similar in its nature to the dropsical affections of the peritoneum, pleura, or pericardium. The swelling is colourless, smooth, and pyriform ; ex tending slowly and gradually upwards from the lower part of the scrotum ; fluctuating, and incapable of reduction or diminution; often there is a degree of transparency, so that the light can be dis cerned through it: but as the tunics va ginalis is frequently thickened, neither this circumstance, nor the fluctuation, can be entirely depended on. The testis cannot be felt, but the spermatic chord may be discerned clearly, in a natural state, above the swelling. The cure is either radical, or palliative : the latter consists in letting out the fluid with a trochar, after which a piece of soap plas ter may be applied, and a bag-truss worn. The fluid accumulates again. In the radi cal cure, the hydrocele should he tapped with a trochar at its anterior and inferior part, and as soon as the. fluid is entirely discharged, the cavity of the tunica vagi nalis is to he distended to its former di mensions, with an injection composed of two parts of red wine, and one of warm water. The 'injection may remain in the part about five minutes, after which it is to be discharged through the trochar. The consequence of this treatment is a considerable inflammation of the part, terminating in the effusion of coagulating lymph, and the consequent obliteration of the cavity of the tunics vaginalis. The inflammation is to be treated like hernia humoralis, if it runs too high.