There are many points to be attended to in this operation; thus the spermatic cord sometimes de scends in front of the tumour running on the sac, but generally it separates into its constituent parts, the plexus of nerves and blood-vessels lying on the inner and anterior aspect, and the vas deferens on the posterior and outer aspect; while in other cases, this order has been reversed. In the ventro inguinal hernia, the epigastric artery runs on the outer or iliac aspect of the neck of the sac. At the period of reducing the protruded viscera, we should examine carefully that two hernia do not exist, or that there is not a second protrusion near the same aperture. We must be also guarded against pushing the viscera between the abdominal muscles, or between the muscles and peritoneum, instead of into the abdomen, which is termed by the French reduction en bloc. We must be satisfied that the viscera are returned into the abdominal cavity; adhesions are occasionally formed between the portions of intestine, or the intestine and omen turn, or between these and the herniary sac, and if recent or of trifling extent, they should be carefully separated by the scalpel, but if the intestine ad heres intimately and extensively to the sac, the stricture is to be freely relieved, and the intestine covered with the integuments, when nature will afterwards reduce it. On the contrary, sometimes an artificial anus is the result. The colour of the protruded intestine ought to he no criterion with regard to reduction; unless it breaks down or rup tures under the fingers, it should be reduced: the colour of a gangrened intestine is commonly brown. The omentum sometimes surrounds the intestine in such a manner as to require to be disentangled. The omentum is also occasionally so con solidated, as to be incapable of being returned without making a prodigious aperture, and even when re turned, it has excited inflammation, suppuration, and mortification. It should therefore be excised, and if the vessels bleed, which are here chiefly veins, they must be secured. A serous fluid is not invariably present in a herniary sac, neither is the herniary sac itself, and in those latter cases, when the colon has been the viscus, it has been proposed not to return it, which, in our opinion, appears injudicious. In a large hernia, the sac should not be opened, as the neck is large enough to allow the reduction of the viscera, and would expose too large a surface; all that is requisite, therefore, is to divide the stricture formed by the muscle on the outer side of the neck of the sac. Congenital inguinal hernia is of most importance when it oc curs in the male, and consists in a protrusion of the viscera, within the tunica vaginalis testis, either with or without a peritoneal sac, and, con sequently, in some instances, in contact with the latter body. In children, as the testis cannot be felt before the viscera are reduced, we require to be careful in the application of the truss; and as children are subject to hydrocele, and these dis eases frequently co-exist, equal caution is requisite. When this variety becomes strangulated, the sac should not be laid open from the bottom, but at the upper margin of the testis, in order that enough may be left to cover the gland: but if any adhe sion exists, the sac must be cut open to the bottom. Sometimes a common inguinal and a congenital hernia exist together.
Crural hernia is said to be peculiar to the female, and inguinal to the male, although our own obser vations do not corroborate this. The viscera are protruded either at the crural aperture, or in the sheath of the femoral vessels, but much more fre quently at the former than the latter place. The stricture in this hernia is generally caused by Gim bernat's ligament, and requires to be divided hori zontally towards the pubes, inserting Weiss's probe pointed bistoury, Fig. 12 of Plate DXVI. as short a distance as possible within the abdomen. There is seldom any serous fluid effused in the sac of femoral hernia, and intestine more frequently than omentum is protruded. The constriction produced on the intestine by the crural aperture, has sometimes caused either permanent contraction of the part, or ulceration of the mucous and muscular tunics, fol lowed by fatal extravasion.
Umbilical is fully more frequently congenital than inguinal, and great circumspection, therefore, is required in securing the umbilical cord at birth. The peritoneal sac in this species becomes exceed ingly thin, and is often ruptured, forming cysts, and the viscera, not unfrequently, adhere to the integu ments, and have been strangulated at these foramina of the sac. It is not very liable to be strangulated, but
when this event does occur, the symptoms are more vi olent, and gangrene takes place more rapidly than in the preceding species, and hence an earlier operation must be had recourse to. The stricture is to be divided either directly upwards or downwards in the linea alba, but the latter should be preferred. Ventral hernia commonly occurs in the linea alba near the umbilicus and between it and the ensiform cartilage. Perinea] hernia is when the viscera pro trude between the urinary bladder and the rectum in man, and between the rectum and vagina in woman, rupturing the fibres of the levator ani mus cle. Vaginal hernia is when the viscera descend either between the urinary bladder and uterus, or between the uterus and rectum. Pudendal hernia is when the viscera protrude between the ramus of the ischium and vagina through the fibres of the leva tor ani muscle, the tumour appearing a little below the middle of the labium externum. Sacro-rectal hernia is a peculiar species arising from an incom plete ossification of the sacrum.
If the intestine which is protruded becomes gan grenous and ruptures, an artificial anus is formed, and if this portion be even so near the anus as the ileum, close to the caput cxcum, the patient dies from inanition. If the intestine at either end ad mits the little finger, there is no necessity for di viding the stricture, if otherwise, there is. The palliative treatment consists in cleanliness, in stop ping up the external aperture by sponge or linen plugs, and ultimately, when the aperture of the in testine is reduced to a small foramen, by applying the actual cautery, and nourishing the individual with nutritive soups and enemata ; the radical cure, in destroying the septem with Dupuytren's forceps, delineated in Fig. 16 of Plate DXVI.; but this in strument ought not to be used too soon after the formation of an artificial anus, and if inflammation is induced, it must be subdued by local blood-letting, fomentations, &c. The external wound is to be af terwards healed by pressure, caustic, and the actual cautery, or paring the edges and employing a su ture. Dupuytren uses an instrument consisting of two pads and a screw, to approximate the sides of this fistulous aperture.
Retention of urine, or ischuria vesicalis is, when the urine is collected in the bladder and cannot be expelled ; and is either partial or total, or complete and incomplete. Partial or incomplete retention is when the patient voids a little urine from time to time, but still his bladder is becoming more and more distended with water, a condition very de ceitful and equally dangerous as the complete, and hence very improperly named. The complete or total state is, when no urine whatever is voided. The causes of this malady are, inflammation of the neck of the bladder or urethra, stricture of the ure thra, diseased prostate gland, fistula in perineo, blood, worms, calculi or other foreign substances in the neck of the bladder or urethra, pressure of the uterus in the advanced stage of gestation, and displacement of the viscera of the pelvis in the fe male, pressure of the rectum, tumours, and ab scesses in the vicinity of the neck of the bladder, paralysis of the bladder, and, in some instances, from a false passage made by the surgeon. In all of these, there is acute pain in the hypogastric re gion, particularly when pressed upon, with a con stant desire to make water, and accompanied with some degree of a fever. On examining the hypo gastric region, the urinary bladder is found dis tended, and more or less of a pyramidal figure • and on inserting the finger in the rectum in the male, or vagina in the female, a bulbous projection is felt. If the urine is allowed to accumulate, the bladder loses its contractile power, inflames, sloughs, and ulti mately ruptures, when the urine escapes into the pel vis, and is extravasated into the contiguous cellular tissue, occasionally upwards to the loins, and down wards to the perineum, scrotum, penis, and upper re gion of the thighs, either exciting inflammation of the peritoneum and viscera, with a typhoid fever ending fatally, or at once producing coma and death. The kidneys, in the advanced stages of retention are mechanically impeded in the further secretion of urine, by this fluid accumulating in the ureters and pelvis of these organs.