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evhere, on the other hand, there has been little or no imperfection in the parts, but where the hernia has been produced by great violence and straining. If, for example, after a severe and long continued engagement at sea, a young, robust, and healthy lad, be suddenly bent down with extreme and enervating pain, and a small, firm, and unelastic tumor be felt in the groin ; he is in the utmost danger, for the opening is small. The violent straining upon the rope, and at the same time an attempt to throw out the car, riage of the gun with his foot, has brought down a small piece of the gut. In this case, the attempt at reduction without in. cision, will often fail ; nay, it will most probably aggravate the symptoms, and the inflammatory stage will quickly lead to gangrene, Suppofe again that a groom, stout, healthy and active, leaps into his faddle with so sudden an exertion as to bring down a hernia; it has the same character, being small, hard, painful, and dangerous, .. Opposed to these cases, is that of predisposition, where there has been no violence. A boy has had a tumor from his in, fancy; or the patient is a man advanced in life, of a fat and relaxed habit; he has felt a fulness in the groin, which has increased gradually, but subsides when he lies down at night; it makes a low grogress, and the symptoms are mild, and by no means alarming: and when, from the irregularity of his bowels, or other accidental circumstance, he requires the assistance of a surgeon, the hernia is cally reduced. These are the extreme cases; and by studying the cause, and attending to the degree of violence, the hardness or softness, and elasticity of the tumor, and the urgency of other general symptoms, the furgeon will in general be able to form a judgement of the propriety of reiterated efforts to reduce the hernia by the hand, or the danger of violence from this rough manuism, and the necessity of incision,
The danger to those who have long laboured under the inconvenience of a hernia, and who wear a truss, is, that by the compression which is necessary to support the parts, there is produced such a degree of callosity or rigidity of the surrounding cellular membrane, with thickening of the neck of the fac, that when, by some unusual exertions, the hernia descends either partially or entirely, the patient comes nearly into the Gituation of those in whom hernia has been produced without any predisposition to the disease, and in whom a small portion of intestine has descended into a narrow and contracted passage. When, on the other hand, the bowels are allowed to remain down, the tumor increases from day to day; and there is danger of strangulation, from the gradual thickening of the neck of the fac; from fome frain, and consequent inflammation and swelling of the cellular membrane, or condensing and conglomeration of the omentum ;
from irregularity of the action of the intestine, included in the hernia; or from collections of indigestible matter within it.
The most important section of a treatise on hernia, must be that which relates to the sac; because all the speculative points, of chief consequence, are connected with this department of the subject; and it is here that the surgeon has to encounter the greatest difficulties in practice. But, instead of finding, in this treatise, a learned, comprehensive, and practical view of this subject, we meet with nothing but the wanderings of a mind led aftray after curious and strange things, without any sober impression of what is truly useful and important. We learn, here, that the peritoneum forms the herniary fac ; but we are not informed how unlike to the internal peritoneum the fac of a hernia becomes: We are not informed how it connects itself by adhesions; how it is obscured by the condensing of the cellular membrane, and the attachment of glands; how the ring and fac coalesce; and how difficult it often is to distinguish their limits. We find that our author has seen thick facś and thin sacs, and sacs through which the vermic cular motion of the intestines could be diftinguished: he has seen also the transparent sac of an umbilical hernia! We can believe that he has seen much ; but we should have been better pleased, if he had pointed out to us the results of his extensive observations, and either traced the analogies by which these varieties are connected in the general system of pathology, or indicated the advantage that practice is likely to receive from his flight notice of those rare and extraordinary cares. : We have been delighted with the display of morbid anatomy, which the museum of Mr J. Hunter affords; while we were chagrined and disappointed with the imperfections of the histories that are now to be obtained of these important cases; doubly important, from having been under the observation of such a man. We did not think, however, that Dr Monro would have had recourse to this collection, without pressing neceflity; and we cannot help suppoing that he has been rather unfortunate in his se. lection of a cafe. For, from the engraving with which we are here presented, and from the exprellion of Mr Hunter, in which he says, it is an example of the manner in which a hernia may be cured, or the mode in which an old hernia is formed, we should fear that our author has miltaken the cale. There is no fuch thing as an old hernia, in the fence in which we speak of an ok coal-pit; and we conceive, that an old herniiry fac nuit have been meint. In this view, the plate is intelligible; for it is a fac infames and adhering, so as to present fereral compartments. We cannet vouch for the accuracy of this interpredation ; but merely recommend a Licond examination of the preparition ; for, to contider this case of Mr Hunter as a collection
of four herniary facs thrown together, and communicating, seems to us a most unlikely supposition.
Connected with this subject of the herniary sac, we have here recalled to our notice the proposal of the elder Dr Monro, for reducing the hernia without opening the fac. Although this proposal be antiquated, yet this alone thould not take from its importance. And as it comes from an authority which we so highly respect, we proceed to give our reafons for considering it as impracticable. In this operation it is proposed to open the skin and tendon only, without opening the fac. When a portion of the intestine is first protruded, the peritoneum, which is carried before it, has its natural character, being a thin and dilatable membrane ; and the situation of the parts is such as an anatomist would make in the dead body, in order to demonstrate the relation of parts. Were the surgeon, then, to operate at the time of the rupture coming down, while yet the fac has not formed its adhefions, and the tendons of the muscles are evidently embracing and constricting the peritoneal fac, he might, after a neat difTection, succeed in reducing the portion of the gut; the fac either being pushed up with it, or being allowed to remain down. But, even in the cafe where the progress of the disease is rapid, and the danger great, we do not find the state of the parts to be such as will admit of the proposed operation.
When a hernia flips down, the tendon embraces the neck of the fac, and, with the surrounding cellular membrane, soon coalesces with it; while the sac, quickly losing its dilatability, becomes inAlamed, thickened, and rigid. Although the tendon of the muscle may be the original cause of the strangulation ; yet, in the latter stage, there would still remain, after its removal, a thick unelastic ring, formed by the neck of the sac. In hernias of some standing, what is called the ring (a term which is improperly applied to the splitting of the tendons in their natural state), is, in a still more particular manner, formed by the fac and common membrane, and less by the constriction of the tendons or ligament.
It must be recollected, that the gut has been down for some time without inconvenience : there has, however, arisen a cause of inflammation in the cellular membrane and peritoneal sac; the parts swell; but, of course, the tendons are stationary; they have Juffered no degree of contraction ; the strangulation arises from the change which has been produced in the neck of the fac, and the contents of the hernia. The tendons may still be considered as the cause ; but their dilatation will not now give any effectual relief; for the neck of the fac has been moulded to the compressed opening, and remains rigid and unyielding. On the other han,',
hending the case, yet knowing how deceitful such symptoms fometimes are, examined and attempted the reduction by such gentle means as they thought the high state of inflammation and tenderness of the parts would bear. An operation having been considered as absolutely necessary, the surgeons were assembled in the morning; when the house-clerk, with no small selfgratulation in his countenance, informed the surgeons that he had reduced the hernia without affistance, and that the mari was completely relieved. The poor man was relieved ; but it was 'by the harbinger of death : gangrene had taken place of pain and great suffering the mortified intestine was indeed rea duced.'
But, in considering this question of the operation proposed by the elder Dr Monro, we must not forget our' author, and that his intention was to write on CRURAL HERNIA. As introductory to this subject, we are favoured with an elaborate, but imperfect description of the crural arch. And here, ainong other matters of great importance, he has discovered that there are distinctions betwixt male and female. The Doctor then pays some compliments to M. Gimbernat, which we really do not conceive to be merited, and proceeds to expatiate on the advantage of his plan of operation. .
If there be any particular object more than the intention of writing implies here, it is to draw a parallel betwixt the operation of M. Gimbernat and the common operation for crural hernia. We are sorry to find, however, that our author leaves us without the fanction of his authority for either manner of operating; his judgement is held in complete suspense, between the novelty of M. Gimbernat's operation, and the merits of that description which he has himself given us of the common method. We shall therefore endeavour to throw out some hints to allilt our readers in forming their judgement on this point.
The study of anatomy must certainly be the principal and fundamental branch of education of him who is to attempt the improvement of surgery—but it is not the whole; for, without having observed the parts in their diseased state (not in bottles), and often having watched the skilful surgeon in his operation, and having also practised with his own hands, most erroneous ideas may be entertained. Gimbernat's operation has evidently been suggested by speculation upon the view of parts in their natural ttate, and not from any observation of the difficulties which embarrass the surgeon in his operation. .
This gentleman, introducing his directory and bistoury on the side of the fac next the pubes (most awkwardly, with both his hands), runs them inwards, so as to cut up the attachment of
the poupart ligament to the os pubis. By this rude operation, there is danger of wounding arteries—there is great danger of wounding the inteftine ; which, being much distended, will, even in the common operation, get before the knife; and much more probably will this happen, when you have got under the protruded bowel, and are cutting with both hands. Those who have seen the operation for the femoral hernia, and have observed the depth of the neck of the sac, and the manner in which the bowel sometimes rises up, and conceals its strangulated part, may forin a just conception of the danger of this deep lateral cut.. Further, the great foundation, and the strength of the ligamentous connexion of all the lower parts of the belly is done away by this operation; of course, it must leave the parts open to fue ture hernia, in a greater degree, than when the operation is performed in the common and approved method.
In regard to the description we have of the operation, as commonly performed, we need only observe, that the author speaks of cutting the tendon, fibre after fibre, without entering the knife deep under the tendon ; which is just our idea; but he afterwards alarms us with a sweep, and extensive incision.'
In concluding, we may obferve, that, through the whole treatise, the author shows a most depraved appetite for strange and uncommon cases, with an unaccountable reluctance to dilo close the results of his investigation. Indeed, we are sometimes led to imagine that he requires some external excitement to divulge his secret knowledge ; for he has a way of saying he knows of a case, which seems to imply that his intelligence and. information are greater than he chooses to express. There is mention made of some facts, to which we should object, did our limits permit: yet we must, at all events, protest against the practice related in the case, p. 17. There are also, we conceive, several mistakes in pathology; which, however, we hope will have no very bad influence upon the practice of surgery. On the subject of the diverticula ilii, and the history of the subject of anus at the groin, he shows a want of reading and investigation, that surprised us; and, instead of speculating on the formation of these appendices, we should recommend to the author's perusal Morgagni, Ruysch, and Palfin, and the papers of M. Mery and M. Liture ( Acad. R. des Sciences ), where he will find both sufficient speculation, and well told cases.
With regard to the following subjects, he is exceedingly deficient:-umbilical hernia ; congenital hernia ; general sympfoms; diagnosis and prognosis. Indeed, were it not for the glaring ti:les, we thould sometimes have been at a loss to discover the fubject of discullion; and yet this small performance is every VOL. 11. NO. 5.
a M. Litiration, and becks, he is: