Paracentesis Abdominis.—To withdraw fluid from the abdominal cavity is an exceedingly simple operation in itself, though certain precautions are necessary to render it safe.

Trocar.—The usual instrument used to be a simple round canula with a trocar, the point of which should be very sharp, and in the shape of a three-sided pyramid. It should be about three inches in length, and a quarter of an inch in diameter. It may for convenience have an india-rubber tube fixed to its side or end, for the purpose of conveying the fluid to the pail or basin, but any other additions or alterations have not been improvements. Lately surgeons have been diminishing the size of the tube so as to withdraw the fluid more slowly, and taking many precautions to insure the wound being kept aseptic.

Where to tap.—In the linea alba, midway between the umbilicus and pubes, or rather nearer the umbilicus. Here, there are no muscles nor vessels, the opening is a dependent one, and the bladder is quite out of the way of injury.

N.B.—It is a wise precaution, in every case where there is a possibility of doubt as to the state of the bladder, to pass a catheter. I have myself known at least one case in which a surgeon was asked to tap an over-distended bladder, as a case of ascites.

The Operation.—As there is great risk of syncope coming on during the operation, from the sudden relief to the pressure on the organs, a broad flannel bandage should be applied to the belly, the ends of which are split into three at each side, and crossed and interlaced behind. An assistant should stand at each side to make gradual pressure by pulling on the ends of the bandage, thus assisting the flow, and maintaining the pressure. A hole should be cut in the bandage at the spot where the puncture is to be made, and the trocar inserted by one firm push, without any preliminary incision, unless the patient is inordinately fat. As the trocar is withdrawn, the canula should be pushed still further in. The surgeon should be ready at once to close the canula with his thumb, if the flow begins to cease, lest air should be admitted. If the flow ceases from any cause before all the fluid seems to be evacuated, the trocar should not be re-introduced, lest the intestines be wounded, but a blunt-headed perforated instrument fitting the canula should be inserted.

When all the fluid that can be easily obtained is evacuated, the canula may be withdrawn, and a pad of lint secured over the wound by strapping.

Gastrotomy.—Cutting into the stomach for the extraction of a foreign body has now been performed at least ten times, and all but one recovered. A typical example is that by Dr. Bell of Davenport, who removed a bar of lead one pound in weight and ten inches in length, by an incision four inches in length from the umbilicus to the false ribs. The opening into the stomach was as small as possible, and required no sutures.

Gastrostomy has within the last few years been practised very frequently. Gross has collected 79 cases, 57 of which were for carcinoma of oesophagus, all of which died within a few weeks, except eight who survived for periods varying from three to seven months. The results in cases of cicatricial and syphilitic strictures are more favourable.—Howse's method seems the best, consisting of two stages.

1. A curved incision is made through the parietes parallel with, and a finger-breadth below, the lower margin of chest wall on left side, the peritoneum should be opened at the linea semilunaris, the stomach sought for, and then attached to the abdominal wall by an outer ring of sutures and to the edge of the wound by an inner ring. It should then be dressed with carbolised lint and supported by a bandage.

2. A small opening should be made four or five days after the first stage and the patient should be fed through this opening.

For full details, see Mr. Durham's paper in vol. i. of Holmes's Surgery, edition of 1883, pp. 801-4.

Gastrectomy.—Excision of whole or part of the stomach is one of the latest developments of operative daring, first done as a regular operation by Pean in 1879, it has now been repeated sixteen times; four cases have survived the operation for more than ten days. The chief points to be attended to are prevention of death from shock and hÆmorrhage, and very careful stitching up of the wound. Considering the difficulty of the diagnosis, the danger of the operation, and the almost certain recurrence of the disease, the propriety of such operation seems very doubtful.

Ovariotomy.—For the pathology of ovarian disease we must refer to Sir Spencer Wells's work on the subject, and to the smaller Monograph on Ovarian Pathology, by the late lamented Dr. Charles Ritchie, junior.

Even the modifications in the method of operating which have been devised are so various and numerous, that if collected from the medical journals of the last ten years they would fill a large volume. Besides this, the operation of ovariotomy is one attended by so many complications, that individual cases vary from each other as much as do individual cases of hernia and tracheotomy; and as the specialities of each case require to be met by specialities of treatment, there is hardly any operation in surgery which requires greater readiness of invention, or more individual sagacity in the operator.

To lay open the abdominal cavity from the sternum to the pubes, and rapidly dissect out of this cavity an enormous tumour with a narrow neck, the operator's only embarrassment being the peristaltic movements of the bowels, and his only care being to tie the neck of the tumour firmly with strong string, sew up the wound, and trust to nature, was an operation very easy to perform, and requiring free cutting rather than dexterity, and rashness more than true surgical insight.

Such were the ovariotomies prior to 1857.

An ovariotomy in 1883 is a very different business, varying in certain important particulars.

(1.) Instead of the incision extending from sternum to pubes, it is now made as short as possible.

(2.) Instead of being removed entire, the cyst is now emptied with the greatest possible care (prior to its removal), and none of the contents allowed to enter the peritoneal cavity.

(3.) The pedicle is brought to the surface, and in every case where it is possible is secured outside the wound.

Besides these three important and cardinal points, there are other minor matters almost equally essential; these are—(1.) The proper management of the adhesions and the thorough prevention of all hÆmorrhage from them; (2.) the stitching up of the external wound, including the peritoneum; (3.) the treatment of the patient during the first few days of convalescence.

Operation in a typical case, after the method of Sir Spencer Wells and Dr. Thomas Keith.—The patient having had her bowels gently opened on the previous day, and being as far as possible in her usual state of health, should be warmly clad in flannel, both in body and limb, and laid on an operating table of convenient height, in or near the room she is to occupy. No carrying from ward to operating theatre and back again is admissible. It will be found both cleanly and convenient to have a large india-rubber cloth over the whole abdomen, cut out in the centre so as to expose so much of the tumour as is necessary, but gummed on or otherwise secured to the sides of the abdomen, and thus protecting the clothes, and hanging down over the edge of the table; this will prevent all wetting of the clothes and unnecessary exposure of the patient's person, and can be easily removed after the operation. Chloroform being administered, the bladder is evacuated by means of a catheter, and the patient's head and shoulders are elevated on pillows. An incision is then made in the linea alba, between the umbilicus and pubes, for about four inches in length at first, so as to be large enough to admit the hand, through all the tissues down to and through the peritoneum. Care is necessary in dividing the peritoneum, on the one hand, not to divide too much, in which case the cyst-wall will be penetrated, and the contents effused into the peritoneal cavity; or, on the other hand, too little, in which case the peritoneum may be mistaken for the cyst, and separated from the transversalis fascia under the idea that adhesions exist. Once the peritoneal cavity is opened, the incision through the peritoneum must be extended to the full length of the external wound by a probe-pointed bistoury.

The operator's hand must now be passed into the abdomen, and the tumour isolated from its connections as far as possible. When no adhesions exist it is extremely easy to pass the hand quite round the tumour, ascertain its relations to the uterus and Fallopian tubes, and the length and thickness of its pedicle. The presence of adhesions adds very seriously to the danger and duration of the operation. We will suppose at present that none exist in this typical case, and that the pedicle is found of a satisfactory size and shape. The surgeon now protrudes the anterior portion of the cyst-wall through the wound, and pierces it with a large trocar,[141] to which is attached an india-rubber tube, by means of which the effused fluid can be easily got rid of in any direction. During the escape of the fluid from the cyst a special assistant keeps up the tension by careful pressure on the abdomen. In cases where the cyst is multilocular, and thus only a portion of the contents of the tumour is at first evaluated, the operator should, by partially withdrawing the trocar, without removing it entirely from the cyst, endeavour to pierce and evacuate the other cysts, still through the original opening in the first one.

While doing this, great care must be taken lest he pierce the external wall of the tumour, and let any of the contents escape into the abdominal cavity; to guard against this, the punctures should be made by the right hand, while the left, re-inserted into the abdomen, supports the cyst-wall.

The tumour having been as far as possible emptied of its fluid contents, must now be dragged out of the wound, care being still taken lest any of its fluid contents escape into the peritoneal cavity. In favourable cases the pedicle is now brought easily into view. This may vary very much in length and thickness. It is sometimes entirely absent, the tumour being sessile on the broad ligament of the uterus; sometimes it is thick and strong, sometimes long and slender. The manner in which it is to be managed depends on its length and thickness. Varieties in treatment will be noticed immediately. We will suppose that it is four inches in length and one or two fingers in breadth. This is quite a suitable case for the use of the clamp, the principle involved in the use of which is, that the pedicle should be brought quite out of the abdomen through the wound and secured on the surface. The best form seems to be one made like a carpenter's callipers, with long but removable handles, and a very powerful fixing-screw.

The blades of this clamp being protected by pads of lint should be made to embrace the pedicle close to the cyst, in a direction at right angles to the abdominal wound, and lying across it, the handles should then be removed, and pads of lint placed below the clamp to protect the skin. The cyst may now be cut away at some little distance above the clamp, enough being left to prevent all danger of its slipping. Further to avoid this danger, the pedicle may be transfixed by one or two needles above the clamp.

The wound is now to be sewed up by several points of interrupted suture, some inserted very deeply through all the tissues, including even the peritoneum, others in the intervals of the first, including little more than the skin. They may be either of iron, silver, platinum, telegraph-wire (Mr. Clover's copper, coated with gutta-percha), or silk. It seems of very little consequence which is used. Sir Spencer Wells, after many trials, uses silk, as being removed with least pain to the patient, and really causing no more suppuration than the metallic ones do, if only removed early enough, viz., about the second or third day, by which time the union of the wound should be firm.

The after-treatment should be very simple. Except under special circumstances, stimulants are rarely necessary, and indeed, to avoid vomiting, as little as possible should be given by the mouth during the first twenty-four hours. The patient should be allowed to suck a little ice to allay thirst, and opiate and nutritive enemata will be found quite sufficient to keep up the strength in ordinary cases. The urine should be drawn off by the catheter every six hours. The room should be kept quiet, and the temperature equable, so long as there is no interference with a plentiful supply of fresh air.

Some of the specialities and abnormalities involving special risks may now be briefly noticed:—

1. Adhesions.—These vary much in amount, in position, in organisation, and danger.

a. In amount.—In certain cases no adhesions exist, while in others, omentum, intestines, tumour, uterus, and abdominal wall may be all matted together in one common mass.

b. In organisation.—Occasionally they are so soft and friable as to break down under the finger with ease, and so slightly organised as not to bleed at all in the process, while again they may be so firm and close as to require a careful and prolonged dissection, and so vascular as to require many points of ligature to be applied to large active vessels.

c. There are special dangers connected with the presence of these adhesions, and varying much in different cases. Thus adhesions to the intestines can generally be separated with comparative ease, and seem, as a rule, to require the application of fewer ligatures than those which unite the tumour to the abdominal wall. Adhesions to the wall are sometimes so firm as to be quite inseparable, and thus to necessitate some of the cyst-wall being left adherent. In Sir Spencer Wells's cases, adhesions to the liver and gall-bladder occasionally occurred, requiring careful dissection to separate them, and yet the patients all survived, while pelvic adhesions, especially to the bladder and uterus, on more than one occasion prevented the completion of the operation.

Vascular adhesions to the wall which require many ligatures certainly add to the dangers of the case, while adhesions to the anterior wall of the abdomen render the operation, especially its first stages, much more difficult, preventing the cyst from being recognised.

2. The condition of the pedicle is of great importance. If it is too short, it prevents the use of the clamp, as if applied it is apt either to pull the uterus up, or, pulling the clamp down, to make undue traction on the wound, and rupture any adhesions. This is especially the case where much flatus is generated, or where the patient is naturally stout.

Treatment.—Where the pedicle is just long enough to allow the clamp to be applied, and yet too short to leave room for any distension of the abdomen without undue tension, the best plan is to transfix it with a stout double thread just below the clamp, tie it in two halves, and bring the threads out past the clamp, so that, if tension does occur, the clamp may be removed, the part beyond it cut off, and the rest allowed to slip back into the pelvis, the ligatures being kept out at the mouth of the wound.

Or again, it is sometimes possible, after applying one clamp firmly as near the tumour as possible, to apply another above it when the greater part of the tumour has been cut away; when the second is firmly fixed it may then be safe to remove the first, and thus an artificially elongated pedicle is obtained.

When still shorter, two plans remain for selection—(1.) to transfix the pedicle in one or more points, then, securing it in two, three, or more portions, cut it off above the ligatures and return it, leaving the ligatures at the lower end of the wound. This gives a free drain for pus, but theoretically the sloughing pedicle might be expected to set up peritonitis; (2.) to transfix and tie the pedicle with one or more loops of stout string, cut the ends off short, and return the whole affair, closing the external wound at once. Theoretically there are grave objections to this plan, but it has proved very successful, especially in the hands of Dr. Tyler Smith.

Another ingenious modification, sometimes useful in a short narrow pedicle, is to tie it as close to the cyst as possible, bring the ligature out at the wound, and then with a strong harelip needle transfix the pedicle, along with both sides of the wound, just below the ligature.

When the pedicle is excessively broad and stout, it should be transfixed by strong needles and double threads in various places, and thus tied in several portions. Absence of the pedicle greatly adds to the danger in any given case. Various plans have been tried, as cutting the attachment through slowly by the Écraseur, ligature of each vessel separately, so many as twelve being sometimes required, and cauterising the stump. The latter, as used by Mr. Baker Brown, has met with a large measure of success, and is much used now.[142]

Dr. Keith for a time operated with antiseptic precautions, but has now (1883) entirely given up the use of the spray, which he believes has especial dangers in abdominal surgery.

Operation for Strangulated Inguinal Hernia.—The great rule to be remembered with regard to this, as well as all other operations for hernia, is, that the earlier it is performed the better chance the patient has. Once a fair trial has been given to the taxis, aided by proper position of the patient, the warm bath, and specially chloroform, the operation should be performed.

The patient should be placed on his back with his shoulders elevated, and the knee of the affected side slightly bent. The groin should then be shaved, and the shape and size of the tumour, with the position of the inguinal canal, carefully studied. The surgeon should then lift up a fold of skin and cellular tissue, in a direction at right angles to the long axis of the tumour, and holding one side of this raised fold in his own left hand, commit the other to an assistant. He then transfixes this fold with a sharp straight bistoury, with its back towards the sac, and cuts outwards, thus at once making an incision along the axis of the hernia without any risk of wounding the sac or bowel. Any vessel that bleeds may now be tied. This incision will be found sufficiently large for most cases; if not, however, it can easily be prolonged either upwards or downwards. The surgeon must now devote his attention to exposing the neck of the sac, and in so doing, defining the external inguinal ring. The safest method of doing so is carefully to pinch up, with dissecting forceps, layer after layer of connective tissue, dividing each separately by the knife held with its flat side, not its edge, on the sac, and then by means of the finger or forceps raising each layer in succession and dividing it to the full extent of the external incision. It is not always an easy matter to recognise the sac, especially as the number of layers above it, which are described in the anatomical text-books, are often not at all distinct.

The thickness of the connective tissue of the part varies immensely; sometimes six layers or even more can be separately dissected, while, again, one only may be found before the sac is exposed.

If small and recent, the sac may be recognised by its bluish colour, and by the fact that it is possible to pinch up a portion of it between the finger and thumb, and thus to rub its opposed surfaces against each other.

If large and of old standing, it is sometimes so thin as not to be recognisable, or again so enormously thickened, and so adherent, as to be defined with great difficulty.

If it is small, i.e. when the whole tumour is under the size of an egg, it ought to be thoroughly isolated, and its boundaries everywhere defined. If large, and specially if adherent, the neck alone should be cleared.

The sac thus being reached, the external abdominal ring should be clearly defined, and the finger passed into it so as if possible to determine the presence or absence of any constriction in it. If it feels tight, the internal pillar of the ring should then be cautiously divided on the finger by a probe-pointed narrow bistoury, in a direction parallel to the linea alba.

At this stage the question comes to be considered as to whether the sac should or should not be opened. Much has been said and written on both sides.

Not to open the sac avoids the risk of peritonitis, and of injury to the bowel; but, on the other hand, exposes the patient to the danger of the hernia being returned unreduced; for in many cases the stricture is to be found in the sac itself, and adhesions very rapidly form between coils of intestine in the sac and the inner wall. Again, not to open the sac prevents us from discovering the condition in which the bowel is; it may possibly be gangrenous, in which case such a return en masse would be almost necessarily fatal.

A general rule or two may be given here:—

1. The sac should be opened in every case where there is any reason for doubt about the condition of the bowel, where there has been long-continued vomiting, or much tenderness on pressure.

2. Even in cases in which there is every reason to believe the bowel is perfectly sound, the sac should be opened, unless the whole contents can be easily and completely reduced out of the sac into the belly, as in cases where this cannot be done there probably exist either a stricture in the neck of the sac itself, or adhesions of the bowel to the sac. We should endeavour to avoid opening the sac in cases of old scrotal hernia of large size, where the symptoms have not been urgent, especially in large unhealthy hospitals, as the risk of peritonitis is so great. Antiseptic precautions seem considerably to diminish the risk of opening the sac.

If the sac then is not to be opened, the rest of the operation is very simple. Endeavour to reduce the bowel out of the sac, and then return the sac itself, unless the hernia is of old standing, and adhesions prevent its reduction. A few silver stitches to close the wound and a carefully adjusted pad are now all that is requisite.

If the sac is to be opened, how can it be done with least danger to the bowel?

If the hernia is small, and it is possible to define it all, the sac should be opened at its lower end, as there a small quantity of serous fluid which intervenes between the sac and the bowel will be found. Where this is present, there is no danger of wounding the bowel, as the sac can be easily pinched up; but this is by no means invariably the case, so great care should always be taken. A small portion of the wall being thus pinched up should be divided in the same manner as the layers of cellular tissue were divided in exposing the sac. A few drops of serum will then escape, and the glistening surface of the bowel be exposed; the finger should then be introduced at the opening, and the incision enlarged by a probe-pointed bistoury. If the hernia is small the sac should be slit up to its full extent; if large, only a sufficient portion of the neck should be opened. As soon as the opening in the sac is large enough to admit the point of the operator's forefinger, it should be inserted so as to protect the intestines, and the remainder of the sac slit up on it as a guide.

The sac thus opened, the next step is to divide the constriction, wherever it be. It is most likely to be found at the neck of the sac, just where it protrudes through the internal ring in an oblique hernia, or through the tendons of the transversalis and internal oblique, where the hernia is direct. Now, this constriction might be divided in any direction were it not for the risk of wounding the epigastric artery, and also of injuring the spermatic cord, which is in close relation to the neck of the sac of an oblique hernia.

Wound of the epigastric artery is the chief danger, for in all cases it is close to the neck of the sac. Were its position in relation to the neck of the sac constant, it might be easily avoided by an incision in the opposite direction; but as this relation varies according to the nature of the hernia, an element of danger is introduced. Thus, in oblique inguinal ruptures, where the sac passes out through the internal ring (Fig. xxxii. ir), the artery will always be found to the inside of the neck of the sac; while in direct herniÆ, where the bowel has made its escape through the triangle of Hesselbach (Fig. xxxii. +), and passed through the conjoint tendon straight to the external ring, the epigastric artery will be found on the outside of the neck of the sac. In recent herniÆ the differential diagnosis is comparatively easy, but in those of old standing and large size, in which the obliquity of the canal has been much diminished, it is almost impossible to tell of what kind the hernia originally was, and consequently to determine in which direction it is safe to incise the neck of the sac.

Such being the case, the best rule is to incise the neck of the sac directly upwards, i.e. in a line parallel with the linea alba, and also to cut it very cautiously bit by bit, in every case, if possible, with the finger inserted as a guide to the position of a vessel and a protection to the gut.

The spermatic vessels lie sometimes behind, sometimes on either side of the sac, and in very old herniÆ may be separated from each other so as really to surround the sac. The cut directly upwards is also the safest for them.

All constrictions being overcome, it is not sufficient merely to push back the gut into the belly. Its condition must be carefully examined, and it must be decided whether the constriction has caused gangrene or not. To examine this properly, it is generally best to pull down an inch or two more of the gut, so as thoroughly to bring into view the constricted portion, as it is most likely to be fatally nipped.

It is not always easy to decide as to the condition of the bowel. Certain points must be observed:—

(1.) Colour.—There may be very great alteration in the colour of the bowel from congestion, and yet no gangrene. It may be dark red, claret, purple, or even have a brownish tint, and yet recover; where it is black, or a deep brown, the prognosis is unfavourable.

(2.) Glistening.—So long as the proper glistening appearance of the bowel remains, there is hope for it, even when the colour is bad; if it has lost it, and especially if, instead of being tense and shining, it is dull and flaccid and in wrinkles, the bowel is almost certainly gangrenous.

(3.) Thickness.—If much thickened, and especially if rough on the surface, the bowel has probably been forming adhesions to the sac, or to contiguous coils, and the prognosis is less favourable.

(4.) Smell.—The peculiar gangrenous odour on opening the sac is very characteristic. In cases where ulceration and perforation have occurred, the odour is fÆcal.

1. If, then, the bowel is tolerably healthy-looking, though discoloured, it should be returned gradually, not en masse, into the abdomen, the wound sewed up, and a pad of lint put on, with a bandage.

2. If there are adhesions of bowel to sac or to a neighbouring coil, or of omentum to sac, the stricture should be freely divided, the protruding coils of intestine should be emptied of their contents, but no rash attempt made to force their return. Especially is this rule to be observed with protruded, swollen, or adherent omentum, for considerable risks attend any attempt at excision of the protruded portion—risks of hÆmorrhage, peritonitis, and ulceration of the contiguous bowel.

If the bowel be returned, or even the continuity of the canal restored by the cutting of the stricture, though the bowel be not returned, no great risks accrue from the retention of a piece of omentum in the sac, in a position which it may possibly have already occupied for years.

3. If the bowel is absolutely gangrenous, even in a very small portion of its length, no reduction should be attempted, but the gangrenous portion should be kept outside, with the hope that adhesive inflammation may be set up, so as to glue the bowel to the abdominal wall, prevent fÆcal extravasation, and form a temporary artificial anus. If the gangrenous portion be very full of fÆces or flatus, incisions may be made into it. This should be avoided in cases where the patient is already much prostrated, as I have seen cases in which the opening of the bowel seemed to inflict a fatal shock.

Enterectomy or excision of the gangrenous portion has recently been recommended and performed by some surgeons. The very high authority of the late Professor Spence is against such procedure.[143]

Cases of gangrene of even large portions of bowel are by no means necessarily fatal. They may recover with an artificial anus, the remedy of which by surgical means we must notice in its proper place.

Operation for Strangulated Femoral Hernia.—While the general principles guiding treatment and ruling the conduct of the operation are the same as in inguinal, there are some differences in points of detail which render a brief separate description necessary.

Operation.—Various incisions are recommended. The one which gives freest access and exposes the sac best, is shaped like a T, the horizontal limb of which is oblique, the direction of the obliquity varying on the two sides. The horizontal incision should be made just over Poupart's ligament, and parallel to it, the centre of the incision corresponding to the neck of the sac, and its length varying according to the size of the tumour and the depth of the parts; the other should extend downwards from the centre of the former, as far as is necessary to display the whole sac. The first should be made by pinching up and transfixing the skin, the second by ordinary incision, to the same depth as the first. The small flaps thus made must now be thrown back; any vessels that have been divided are to be tied. Now, with great care and caution the surgeon is to pinch up and divide any layers of condensed cellular tissue which may still cover the sac, till it is thoroughly exposed to its full extent, and remove any glands which may intervene.

The neck of the sac being exposed, it may be possible in some very exceptional cases to give the patient the benefit of the minor operation, which consists in leaving the sac unopened. In such a case (to be described immediately), the surgeon passes his finger along the neck of the sac as far as possible into the ring, and then with a probe-pointed bistoury very cautiously nicks the upper edge of Gimbernat's ligament, in one or more places, being careful to feel for any pulsation before dividing a single fibre. He may then be able to empty the sac of its contents, and return the bowel and omentum, still retaining the sac outside.

On the other hand, where it is determined to open the sac, the pinching up of the sac must be managed with great care, to avoid injury of the bowel. There is generally a little fluid to be found at the fundus, which will protect the bowel. In one case in which Liston operated, he tells us, "there was no possibility of pinching up the sac, either with the fingers or forceps; it contained no fluid, and was impacted most firmly with bowel; very luckily the membrane was thin; and, observing a pelleton of fat underneath, I scratched very cautiously with the point of the knife in the unsupported hand, until a trifling puncture was made, sufficient to admit the blunt point of a narrow bistoury."[144] If the sac contains bowel and omentum, it is safer to open it over the omentum than over the bowel. When a small opening is made, an escape of the contained fluid takes place, and then the sac should be slit up as far as its neck by a probe-pointed bistoury, guided by the finger, introduced to protect the bowel, whenever the opening is sufficiently large. The forefinger must now be cautiously insinuated into the neck of the sac, the nail being directed to the bowel, the pulp to the crescentic margin of Gimbernat's ligament, and any constriction very cautiously divided. The bowel should then be drawn down a little, the constricted point carefully examined, and then returned or not, according to its condition.

Two points require a brief separate notice:—

1. In what direction is the crural arch to be divided? Not outwards certainly, on account of the vein, nor downwards, as the bone prevents that direction. Is it to be upwards or inwards? Not upwards, for such an incision would endanger the spermatic cord or round ligament, besides greatly weakening the abdominal wall by the division, partial or complete, of Poupart's ligament. Inwards then it must be; and little more need be said about it, were it not for the occasional existence of an abnormal course and distribution of the obturator artery.

The usual origin of this vessel is from the internal iliac, in which case (Fig. xxxii. n o) it never comes near the sac at all. In certain cases (1 in 3½) it rises from the epigastric, and in a very few (1 in 72) from the external iliac. If rising from either of the two last, it most commonly passes downwards at the outer side of the hernia, in which case (Fig. xxxii. s o) no harm can possibly result; but in a few rare cases, perhaps 1 in every 60 of those operated on, the vessel winds round the hernia (Fig. xxxii. o), crossing at its inner side, and thus may be (and has actually been) divided by a rash incision. With due care, however, and by cutting a very little at a time, even this danger may be avoided.

2. Under what circumstances is it possible or justifiable to reduce a femoral hernia, without previously opening the sac? Only in certain very select cases, where the hernia is recent, the constricting parts lax, the general symptoms very mild, and where there is reason to believe the bowel has completely escaped injury by compression or the taxis. There are both difficulties and dangers in this so-called minor operation:—1. Difficulties, For it is not easy to divide the constriction without the assistance of the finger in the sac, and it is not easy to reduce the contents with the sac unopened, except through a much freer opening than is necessary when the bowel has been fairly exposed. 2. Dangers, Of reducing sac and viscera, together with the strangulation still kept up by tightness in the neck of the sac; or of supposing the sac is emptied while a knuckle of bowel still remains in it, and is strangulated; or, lastly, of reducing the intestine which has already become gangrenous. It is very remarkable how very soon gangrene may come on, in a case of a small recent femoral hernia, in which the fibrous tissues constricting the neck of the sac are tense and undilatable. A protrusion for eight hours has been sufficient to destroy the life of a knuckle of bowel.

Operation for Strangulated Umbilical Hernia.—The operation is practically the same, whether the hernia is a true umbilical one, or one which with more strict accuracy might be called ventral. True umbilical hernia is a disease of infancy and childhood, being almost always congenital, and the viscera protrude through the umbilical aperture. This rarely requires operation, as it may generally be returned with ease, and even cured by a proper bandage and compress. Ventral hernia, commonly called umbilical, is generally a protrusion of viscera through a new preternatural aperture in the fibrous tissues close to the navel, may often attain a large size, is liable to strangulation, and is not easily palliated or cured.

In either case the operation requires a very brief description. If the hernia is small, under the size of a hen's egg, a crucial incision through the thin skin which covers it will thoroughly expose the sac when the flaps are dissected back. The forefinger should then be inserted in the round opening, and the edges cautiously incised in several directions, each incision however being very small.

If the rupture is large, a single linear, or a T-shaped incision, exposing the base of the tumour, will be sufficient to allow the requisite dilatation of the opening to be made. It is not at all necessary in every case to open the sac of the peritoneum. If required, it must be done with great caution, as the sac is generally very thin. In cases where the hernia is chiefly omental, the sac should be opened, lest a knuckle of bowel be inclosed and strangulated in the omentum.

Obturator Hernia is an extremely rare lesion, and a large proportion of the recorded cases were discovered only after death. When diagnosed during life and strangulated, some have been reduced by taxis, and only a very few cases have been operated on, some with success. It is not likely that a diagnosis could be made, except in very emaciated patients, in whom pain at the obturator foramen was a prominent symptom, and in whom it could be ascertained positively that the crural ring was empty. An incision over the tumour, sufficient to allow the pectineus muscle to be exposed and divided, is necessary. The hernia may then be reduced without opening the sac, if recent; if of long standing, the sac must be opened. One case is recorded by Dr. Lorinzer, in which, after strangulation for eleven days, he opened the sac and found the bowel gangrenous. The patient had a fÆcal fistula; but survived the operation for eleven months. Nuttel, ObrÈ, and Bransby Cooper have each diagnosed and treated such cases.[146]

Other forms of hernia are so rare, and the treatment of each case must necessarily vary so much in its circumstances, as not to require or admit of any detailed account of the operations requisite for their relief.

Operations for the Radical Cure of Hernia.—The inconveniences and discomfort caused by even the best-adjusted trusses or bandages, the unsatisfactory support they afford, and the risk of their slipping and allowing the hernia to escape, have given rise to many attempts to cure hernia by operation.

Even to enumerate these would be quite beyond the limits of the present volume; suffice it to classify a few of the most important of them according to the principle involved in each, and then give a very brief account of the method of operating which seems to be at once the most scientific, least dangerous, and most permanently useful.

The question at issue is briefly this. We have, in a hernia, the following condition:—The walls of a great cavity are at one or more points specially weak, the contained viscera have protruded, either by extension and stretching of a natural opening, or by the formation of a new breach in the walls, and, in protruding, they have brought with them as a covering a serous membrane, extremely extensible, highly sensitive to injury, and, when injured, certain to resent it by severe, spreading, and dangerous inflammation.

Do we desire to remedy this protrusion, we may act—

1. On the intestines themselves; but for all surgical purposes, they are out of our reach. We cannot do more than, by diminishing their contents, diminish their volume, and by position and rest reduce to the utmost their tendency to protrude. This includes the medical and prophylactic treatment of hernia, or rather of the tendency to hernia.

2. We may try what can be done with the sac which the intestines have pushed down before them. Can it be obliterated? If it can, perhaps the intestines may be retained in their cavity. Very many plans of dealing with the sac have been tried.

To cause obliteration of its cavity many methods have been proposed:—by ligature of it along with the spermatic cord, involving loss of the testicle, either by gradual separation, by sloughing, or by immediate removal;—by cutting into it, and then stitching it up;—by constricting it with wire, as in the punctum aureum; by pinching sac and coverings up, by passing needles under them as they emerge from the external ring, as Bonnet of Lyons did; by constricting sac alone with a double wire, by subcutaneous puncture, as Dr. Morton of Glasgow has done;—by severe pressure from the outside with a strong tight truss and a pad of wood, as proposed by Richter; by setons of threads or candlewicks, as proposed by Schuh of Vienna;—by injection of tincture of iodine or cantharides, as by Velpeau and Pancoast;—by the introduction into the sac of thin bladders of goldbeaters' skin, which were then filled with air, and were intended to excite inflammation, as in the radical cure of hydrocele; or by the still more severe method of Langenbeck, consisting in exposing the sac by a free incision at the superficial ring, separating it from the cord, and passing a ligature round the sac alone, leaving the ligatured portion in the scrotum either to become obliterated or to slough out. Schmucker of Berlin varied this, by cutting away the constricted portion below the ligature.

The objections to these methods are various: the more gentle are uncertain and inefficient; of the more severe, some involve mutilation, by the loss or removal of the testicle; others, as those of Langenbeck and Schmucker, are very dangerous and fatal, by the inflammation spreading to the peritoneal cavity (20 to 30 per cent. died); while all of these methods afford at best only temporary relief. And this is only what might have been expected, for the sac was only a result of the protrusion, not a cause; and so long as the weakness and insufficiency of the parietes of the abdomen remain, so long will the extensible loosely-attached peritoneum continue to furnish new sacs for visceral protrusions.

3. We have now only the canal left to act upon; and the operations on the canal may be divided into two great classes:—

(a.) Those in which the operator attempts to plug up the dilated canal. (b.) Those in which he tries to constrict it, by reuniting its separated sides.

(a.) Attempts to plug the canal have, in most cases, been made by invagination of the skin of the scrotum and its fascia. These have been very numerous and various in their adaptation of mechanical appliances, but have all been designed with the same object. Dzondi of Halle, and Jameson of Baltimore, incised lancet-shaped flaps of skin, and endeavoured to fix them by displacement over the ring. Gerdy invaginated a portion of scrotum and fascia into the enlarged canal, by the forefinger pushed it up, and secured it in its place by a thread passed from the point of his finger first through the invaginated skin, then through the abdominal walls, endeavouring to include the walls of the inguinal canal, causing the point of the needle to project some lines above the inguinal ring; the same process being effected with the other end of the thread on the other side of the finger, and the two ends which have been brought out near each other on the abdominal wall, being tied tightly over a cylinder of plaster. The ensheathed sac was then painted with caustic ammonia to excite inflammation, and a pad put on over all.

Signoroni modified this by fixing the invaginated skin by a piece of female catheter, retained in its place by transfixion by three harelip needles, tied by twisted sutures.

WÜtzer of Bonn, again, modified this, by substituting a complicated instrument, consisting of a stout plug in the inguinal canal, held in position by needles which are passed through the anterior wall of the canal in the groin. Compression between plug and compress, with the intention of causing adhesion between skin, fascia, and sac, is then managed by means of a screw. The plug is retained for about seven days.

Modifications of this method have been tried by Wells, Rothmund, and Redfern Davies, all aiming in the direction of simplicity; but by far the most simple and efficacious method on the WÜtzer principle yet devised is that of Professor Syme, which he described in the pages of the Edinburgh Medical Journal for May 1861, in which the invagination of integument is both simply and securely managed by strong threads, as in Gerdy's method, while a piece of bougie or gutta-percha, to which the threads are fixed, replaces WÜtzer's expensive and complicated apparatus. Sir J. Fayrer of Calcutta has had a very large experience of WÜtzer's method, and also of a plan of his own. Out of 102 cases by the latter method, 77 were cured, 9 relieved, 14 failed, and 2 died.[147]

Mr. Pritchard of Bristol has proposed an additional step in operations on the invagination principle, consisting in the stripping of a thin slip of skin from the orifice of the cutaneous canal, and then putting a pin through the parts to get them to unite, and thus close the aperture completely.

Now, what results follow these operations? At first they are almost invariably successful, but the complaint is that, in most cases, the rupture recurs. The principle is to plug up the passage by the mechanical presence of the invaginated skin, the plug being retained in position by adhesive inflammation between it and the edges of the dilated ring. But the ring is left dilated, or, indeed, generally its dilatation is increased; and as, on continued pressure from within, the new adhesions give way, or, as often happens, a new protrusion takes place in the circular cul-de-sac necessarily left all round the apex of the invagination, the still lax ring and canal offer no resistance to the protrusion.

(b.) The principle of constriction of the canal by reuniting its separated sides. This is the principle of the various methods introduced by Mr. Wood of King's College, and described by him in his most able and exhaustive work.[148]

He applies sutures through the sides of the dilated inguinal or crural canals, or umbilical openings, in such a manner as to insure their complete closure.

1. For inguinal hernia.—To stitch together the two sides of the canal with safety requires attention to several points—(1.) That it be done nearly, if not entirely, subcutaneously. (2.) That the protruding bowel should be kept out of the way, and not be transfixed by the needle. (3.) That the spermatic cord should be protected from injurious pressure.

These different indications are attained by Mr. Wood by a very ingenious mode of operating, which I can describe here only briefly, and for a full description of which I must refer to Mr. Wood's own monograph already alluded to.

For his first twenty cases Mr. Wood used strong hempen thread for the stitches; of late, however, he has proved the greater advantage of strong wire.

When a large old hernia in an adult is the subject of operation, it is thus performed by Mr. Wood:—The pubes being shaved, and the patient put thoroughly under the influence of chloroform, the rupture is reduced, and the operator's forefinger forced up the canal so as to push every morsel of bowel fairly into the abdomen. An assistant then commands the internal ring by pressure, to prevent return of the rupture.

An incision is made in the scrotum over the fundus of the sac, large enough to admit a forefinger and the large needle used in the operation; the edges of the skin are to be separated from the fascia below for about one inch all round. The forefinger is then to be passed in at the aperture and pushed upwards, invaginating the detached fascia before it, and it must be made to enter the inguinal canal far enough to define the lower border of the internal oblique muscle stretched over it. A large curved needle (unarmed) is then passed on the finger as a guide, through the internal oblique tendon, the internal portion of the ring, and the skin of the abdomen; it is then threaded and withdrawn. Again, the needle (now with a thread) is guided by the finger and pushed through Poupart's ligament and the external pillar of the ring as before; while by a little manipulation its point is made to protrude through the same opening in the skin as before, a loop of thread is now left there, and the needle, still threaded, is again withdrawn. The next stitch, still guided on the finger, takes up the tendinous layer of the triangular aponeurosis covering the outer border of the rectus tendon close to the pubic spine; the point of the needle is then turned obliquely, so as to protrude through the original puncture in the skin a third time, the needle is then freed from the thread and withdrawn, thus leaving two ends and one intermediate loop of thread all at the one opening. These are so arranged that when they are tightened they draw together the sides of the canal; they are then secured over a compress of lint. The compress is removed and the stitches loosened, at dates varying from the third to the seventh day.

Mr. Wood now uses wire instead of thread. It has the advantage of greater firmness, excites less suppuration, and may be left much longer in situ, in consequence of which there is less risk of suppuration or pyÆmia, and more chance of a good consolidation of the parts.

In congenital herniÆ, and small ruptures in children and young boys, Mr. Wood uses rectangular pins in the following manner:—The scrotum being invaginated (without any incision through the skin) as far as possible up the canal, a rectangular pin, with a slightly-curved spear-pointed head, is passed through the skin of the groin to the operator's forefinger; guided by it, it is brought safely down the canal, and brought out through the skin of the scrotum just over the fundus of the hernial sac. A second pin is passed from the lower opening (still guided by the finger) in an upward direction, transfixing in its course the posterior surface of the outer pillar of the superficial ring, its point being brought out through, or at least close to, the first puncture made by the first pin. The pins are then locked in each other's loops—the punctures and skin protected by lint or adhesive plaster,—and the whole is retained by lint and a spica bandage. The pins should generally be withdrawn about the tenth day.