my cases which were successful happened after the fatal case just mentioned. I certainly should not be disposed to adopt or recommend the practice proposed by CHELIUS, of separating the adhesions at the neck of the sac, and passing a piece of linen round the omentum, with the purpose of dividing it at a future time, as I should expect that the presence of such extraneous substance would be likely to excite dangerous inflammation.

(2) As to the adhesions between the omentum and gut, if they cannot be easily separated with the finger, they are best left alone, without attempting further separation or their return, to take their chance together, either to remain in the sac, or return of their own accord into the belly.

(3) There is in the Museum of the Royal College of Surgeons of England, a preparation of a portion of strangulated small intestine, which not being returnable on account of the great quantity of air it contained, was cut into, to the extent of an inch, and left in the sac, and the patient died. I cannot imagine there is any necessity for puncturing the intestine to compel its return into the belly, provided the stricture be freely divided; for I know by experience, that if strangulation be relieved, it is of little consequence how much intestine be down. In reference to this point, I recollect the largest scrotal rupture on which I have operated, and in which, before the division of the stricture, there was at least half a yard of bowel down, filled with air; and, after the stricture had been cut through, at least as much more thrust through, so that I almost despaired of getting any back; yet after a time I returned the whole. To my vexation, however, next morning I found my patient had got out of bed to relieve himself on the chamber-pot, and as might be expected, the bowel had descended, and in such quantity, that the scrotum was at least as big as a quart pot, and the vermicular motion of the intestine was distinctly seen through the stretched skin. Nothing further was done than to keep the tumour raised above the level of the abdominal ring, by placing a pillow beneath it, and by degrees it returned, and the patient never had an untoward symptom.

If, however, the bowel be filled with solid matter, as hard stool, or apple or potato skin, and its return thus prevented, as well as the passage through it stopped up, an instance of which latter kind is in the College Museum, then the loaded gut ought to be cut into freely without hesitation, as the only means of perhaps saving the patient's life. But such cases I suspect are exceedingly rare.-J. F. S.]

1178. If the omentum be converted into a tangled lump, it must not be returned into the belly, because it requires a too large dilatation of the abdominal ring, and this degenerated mass may produce inflammation and even suppuration in the cavity of the belly. The general advice in these cases, is to tie the omentum above the degenerated part, to cut it off below the ligature, to return the tied part into the belly, and to fasten the threads externally. The ligature of the omentum, however, causes a new strangulation (1).

Experiments on animals, and numerous practices upon man, show that the omentum, cut off and without tying, may be returned into the belly without injury (2). But if the vessels of the cut edge of the omentum bleed they must be tied singly and the threads allowed to hang out externally, or torsion must be performed on them (3). The recommendation of allowing such diseased pieces of omentum to lie out, (POUTEau, DeSAULT, VOLPI, ZANG, and others,) proves the objection, that by fastening the omentum in this position, severe disturbance of the stomach and so on may be produced. If the omentum be sloughy, the sloughy part must be removed with scissors, and treated in the way prescribed. In these cases, generally the omentum becomes adherent to the neck of the sac, which it then closes like a plug.

[(1) I have tied the omentum, and cut off the part below the ligature several times, without any of the untoward results commonly, and as by CHELIUS, assigned to this practice.

(2) The largest portion of omentum I have known removed was seven ounces and a half, in a case of scrotal rupture, in a man forty-two years of age, under CALLAWAY'S care; he recovered, and the preparation is in the Museum of Guy's Hospital.

KEY (a) advises, that "the omentum should be unfolded before it is divided by the knife; otherwise the cutting off the omentum in a mass prevents all the vessels being seen, and when returned into the abdomen they bleed profusely." A case of this kind happened to him, in which he cut off "a large portion of omentum with one stroke of the knife, securing the bleeding arteries before returning it to the mouth of the sac. In four hours after the operation blood of an arterial colour began to ooze from the sac, and soon increased in quantity to alarm the dresser. He used pressure and cold to no purpose. Her pulse began to falter, and her face was bedewed with a cold perspiration; and in this state I found her, when early on the following morning I was called to see her. It was evident she had lost a very large quantity of blood, and had she not been possessed of an unimpaired constitution, she could not have supported the loss. I opened the sac, removed the coagulum with which it was filled, and was proceeding to look for the bleeding vessels of the omentum, when I fortunately observed the hemorrhage had suddenly ceased. The only ill effect of the hæmorrhage was the disturbance of the adhesive process, and the consequent suppuration in the sac, as she ultimately perfectly recovered." (p. 43, note.)

When necessary to remove omentum I generally tear it off as far as possible, and afterwards cut through the part which will not tear. I have rarely had occasion to apply any ligatures.

Sometimes if the omentum be left, it sloughs; I have seen this happen two or three times without any inconvenience. ASTLEY COOPER (b) mentions a case in which both omentum and intestine were returned into the belly, and after the operation the patient complained of severe pain in the belly; the ligatures on the wound in the scrotum were removed; on the following day a small portion of gangrenous omentum protruded, more and more gradually descended, till the whole which had been protruded appeared in the wound, sloughed, and the patient recovered. (p. 44.)

HEWETT has recently (c) given a good account of some cases in which the omentum had formed a complete bag around the intestine in strangulated rupture. Although RICHTER has been stated to have had cases of this kind, yet appears that he merely notices their existence without mentioning any particular instance, and HEY's cases cannot be admitted as belonging to this class. HEWETT states that "these sacs have been found in the three most common forms of hernia; but it is in the umbilical hernia they have been generally observed; the relative situation of the intestine and the omentum in the abdominal cavity will easily explain the fact. Complete omental sacs were found in four cases out of thirty-four operations for strangulated hernia, performed at St. George's Hospital in 1842-43; of these four cases two were femoral, one inguinal, and one umbilical. The formation of these sacs is attributed by RICHTER to the firm agglutination of the margins of the omentum which has surrounded the bowel. In this explanation of RICHTER'S, which does not appear to be applicable to the majority of cases, the two following explanations of the manner in which these sacs are in some cases formed have been added:-First, the gut, completely enveloped by the omentum, passes through the ring, and the omentum thus disposed round the intestine becomes attached to the circumference of the neck of the hernial sac; this omental pouch is subsequently distended by the intestine, and thus forms a complete lining to the hernial sac. Second, an epiplocele takes place, and the portion of omentum which is protruded becomes altered in structure, and its folds firmly united to each other by the effusion of lymph; but within the abdominal cavity, in the neighbourhood of the ring, the fold, into which the omentum has been drawn may not be agglutinated; they will thus leave spaces into which a knuckle of intestine may insinuate itself, pass through the rings and form for itself a bed in the altered mass of omentum which is in the hernial sac. It may happen that two or three portions of gut may slip into the different spaces left between the folds of the omentum, and subsequently form for themselves separate pouches. Several separate sacs, with narrow necks, may be thus found in the omental mass, which is in the hernial sac. Once formed, these sacs may attain an immense size. In one case the sac measured six inches in length, and eleven inches in circumference at its broadest part. The omentum in which a sac has been formed, may in the course of time, especially if it is irreducible, become altered in structure, either by the effusion of lymph or by a deposition of fat, which takes place in the walls of the sac. By this alteration of structure the thickened sac may, in an operation, become the source of very great difficulties. ***These omental sacs may either lie loose in the cavity of the hernial sac, or the two sacs may have contracted more or less extensive and firm

(a) Cooper's Hernia, above cited.

(6) Above cited.

(e) Observations on the Omental Sacs which are

sometimes found in Strangulated Herniæ completely enveloping the intestine; in Med.-Chir. Trans, vol. xxvii. 1844.

adhesions with each other. (p. 284-87.) The neck of an omental sac may become the sole cause of strangulation, of which an instance is given. "The division of the neck of these omental sacs may be followed by hæmorrhage," of which he also mentions a case; the external bleeding at the operation was slight, and soon ceased; but after death a large patch of recently effused blood was found in the folds of the omentum near the mouth of the sac. (pp. 291, 92.)]

(3) If the blood have not coagulated in the vessels of the omentum, cutting it off and tying them singly is not only an almost interminable business, but also when apparently all the vessels have been secured, and the patient put to bed, after a few hours secondary bleeding occurs from some little vessel or vessels which had escaped notice, the sac and yielding skin become largely distended with blood, in such quantity as to produce faintness, and require the reopening of the wound to remove the blood and tie the bleeding vessels. This disturbance of the wound prevents the adhesive process, and very commonly gives rise to abscess in the sac or its immediate neighbourhood, by which the cure is much retarded. A case of this kind occurred to me, and a large abscess was the result, although the patient ultimately recovered. It is on this account I prefer tearing through the omentum as much as possible, by which the ends of the vessels are ensheathed in cellular tissue, and do not bleed, or even tying up the omentum together.

The occurrence of abscess in the sac, independent of bleeding, and which sometimes reproduces symptoms of strangulation, has been noticed by KEY, as will be presently seen (p. 49); first, in a case which occurred at St. Thomas's Hospital in 1817, which I remember to have noted; and secondly, in a case of his own.-J. F. S.]

1179. If the intestine have a dark, violet, even dusky colour, and its warmth be diminished, these must not prevent its reduction; only, according to some, the precaution should be taken of drawing a loop through the mesentery, for the purpose of keeping the returned intestine in the neighbourhood of the abdominal ring, and to afford a more free escape to the stool, if a part of the returned intestine be destroyed by gangrene.

[It not unfrequently happens, that though an intestine be a dark-chocolate colour when the sac is first opened, yet immediately after the division of the stricture, the colour, which has depended only on venous congestion, begins to alter, and the gut becomes florid. This is always a very encouraging sign.-J. F. S.]

1180. If the gangrene be more severe, which is characterized by loss of gloss, by an ashy-gray colour, by a softened condition, by the easy peeling off of the outer membrane of the intestine, if the gangrenous portion be but small, it must be opened with a lancet, and the gangrenous part fastened in a corresponding position to the abdominal ring. If a loop of intestine be attacked with gangrene, and the continuity of the intestinal canal destroyed, the gangrenous part must simply be cut off with scissors, as by the previous inflammation, adhesion of the rest of the intestine with the hernial sac has been effected, which prevents all effusion of stool into the belly. If the excrement will not escape of itself, an elastic sound must be introduced. The enlargement of the mouth of the sac with the knife is dangerous, as the division easily overshoots the boundary of the adhesion and may cause effusion into the belly.

Stitching up the intestine after cutting off the gangrenous part, as proposed and performed in various ways, is objectionable, as the stitch not holding the inflamed intestinal membranes, produces extension of the inflammation and gangrene.

1181. If in the protruded bowel any wounding substance be found, it must be removed by the wound; if the intestine be so narrowed and degenerated that it can no longer allow the passage of the stools, that part must be cut off, the wound brought together, by means of LEMBERT's stitch; or the intestine must be fixed in the abdominal ring, by a twist of the mesentery. In very small wounds only of the intestines, may the little opening be tied up with a silk thread (A. COOPER.)

1182. If in an old and bulky rupture, it be certain that it is not possible

to return the contained parts, on account of the great adhesion and degeneration, the hernial sac must merely be laid bare at the abdominal ring, the strangulation relieved, and the rupture left where it was (1).

That mode of operating in which the hernial sac is not to be at all opened, but only the abdominal ring dilated so as to return the hernial sac together with the intestine, is, in general, to be rejected, and the not opening of the sac to be most especially confined to those cases in which it is certain that in a recently produced or extraordinary large rupture, or in a rupture entirely adhering to the neck of the sac, the strangulation is seated in the abdominal ring. In most cases the connexion between the aponeurotic opening and the hernial sac is so firm that the blunt end of a knife cannot be inserted between them, especially if a truss have been already worn (2).

Although FRANCO and PARÉ had cut into the abdominal ring and did not open the hernial sac, except when reduction could not be effected, yet the practice was first generally recommended by PETIT, in large and adherent ruptures; after him, by GARENGEOT and MONRO, in recent and small ruptures, and more recently by A. COOPER; but especially by KEY (a) and PREISS (b) has it been laid down, to a certain extent, as the proper practice (2). The advantages resulting therefrom, are diminution of the danger, as the hernial sac is not injured; as well as that by keeping the air from the cavity of the belly inflammation, in any injury of an artery effusion of blood into the belly, and also injuring and tearing the intestine in incipient gangrene, are prevented; and when it seems necessary, the opening of the hernial sac can always be made. These benefits are, however, sufficiently outweighed by the disadvantages, that without opening the sac no insight can be obtained of the state and condition of the parts, the tightness at the neck of the sac may be caused by the entanglement of the intestine and by the peculiar position of the omentum, and the operation, especially in stout persons, is very difficult, and therefore only to be confined to the above-mentioned cases." With this mode of treatment must be placed GUERIN'S (c) subcutaneous incision of the abdominal ring, which he would employ in all ruptures with recent strangulation from the ring, where, however, no sloughy destruction of the loop of intestine is to be feared. In strangulation by the hernial sac it is not applicable.

[(1) When a rupture is large and old, Surgeons generally follow ASTLEY COOPER'S recommendation, of dividing the stricture without opening the sac and leaving the protruded gut in the sac or not, as may be. For this he assigns the following reasons:--"first, in very large old hernia, the cavity of the abdomen is so much diminished by the habitual loss of the protruded intestine and omentum, that it becomes scarcely able to receive them again; and if a reduction is attempted, the force necessary to effect it endangers the bursting of the intestine; second, a large surface of intestine is exposed and handled for so long a time, as to produce, even if it does not give way, the risk of an inflammation which will probably be attended with fatal consequences; third, if by great pains the intestine be returned, it is scarcely possible to keep it in the now over distended abdomen, so that the slightest cough, or effort of any kind, is sufficient to bring it again down into the sac, and thus induce a high and dangerous inflammation; lastly, when great adhesion occurs, so much time is necessarily required in performing the operation, to separate the united surfaces, that fears may be justly entertained of the patient not surviving the operation. *** Hence, in these cases, I would advise only the division of the abdominal ring; or if the stricture is higher up, of the lower edge of the transversalis muscle; but the hernial sac should not be opened, unless the stricture is situated in the sac itself." His mode of performing the operation he thus describes:-"I made an incision three inches in length, immediately over the abdominal ring, exposing it with the knife, as well as the fascia, which it sends off. I then made a hole in the fascia large enough to introduce a director, which I thrust up behind the abdominal ring, between it and the hernial sac; and passing a curved probe-pointed bistoury upon it I divided the ring. I then introduced my finger, and feeling some resistance from the transversalis, I carried the bistoury upon the director up to it, and divided this also." (p. 63.) It is rather odd, in referring to COOPER's first reason for following this practice, that the case on which the operation just described

(a) Memoir on the advantages and practicability of dividing the stricture in Strangulated Hernia on the outside of the sac. London, 1833.

(b) Würdigung des Bruchschnittes ohne Eröff nung des Bruchsackes. Wien, 1837.

(c) Gazette Médicale de Paris, 1841. No. 33.

was performed, "had existed from the patient's (aged fifty-four) earliest years," and that it "was of enormous size, reaching half-way to the knees," yet after the division of the stricture, "it went up with a gurgling noise, as soon as his hand was laid upon the tumour." And as regards the danger of exposing and handling for a long time a large surface of intestine, as laid down in his second reason for not opening the sac, the only case he refers to is CARPENTER'S, who says:-"It was the largest hernia I ever remember to have seen;" and, having opened the sac "a large quantity of intestine, with a small piece of omentum protruded;" but after dividing the stricture, the adhesions were so great, that he "judged it advisable not to attempt their separation. And from the size of the hernia, it was quite impossible to bring the integuments over the intestine, which was therefore left exposed to the air;" yet nothing untoward ensued; “the intestine soon began to granulate, and gradually shrunk within the wound," and the patient recovered. (p. 64.)

This is the operation on which ASTLEY COOPER lays so great stress, observing:— "I feel convinced that this operation will be gradually introduced into general practice when it has been fairly tried, and found, if performed early, to be free from danger, and attended with no unusual difficulty." (p. 64.)

"If we cannot accomplish our object in this manner," says LAWRENCE, "a small aperture may be made in the sac, near the ring, which will enable the Surgeon to introduce a curved director under the stricture; the knife carried along the groove, divides the tendon with ease. When the parts are thus set free, they should be returned into the belly by pressure on the swelling, if adhesions do not prevent this; at all events, they generally admit of being replaced in part." (p. 285.)

(2) I do not think it can be fairly stated from ASTLEY COOPER'S published statements, that he is in the generality of cases favourable to, or that he recommends the practice of dividing the stricture, in strangulated rupture external to the sac, but only lays it down as the general rule in large ruptures. It is quite true that in his great work on HERNIA, in the first part of the first edition, when treating of the operation for inguinal rupture, he says:-"An advantage is derived from dilating the stricture without cutting the sac itself, for there is no danger of injuring the intestine, &c." (p. 30); and in the second edition he speaks more at length on the subject thus:-"I have occasionally practised, and for some time recommended in my lectures the following mode of dividing the stricture without including the sac. The tendon of the external oblique having been divided a little above the external ring, the sac is gently drawn down, while the muscles are drawn up by an assistant. In this way the stricture is brought into view, and can be divided without risk, and without including the peritoneum." (p. 39); and he then enumerates the advantages from this practice, that there is no danger of wounding the intestine, and that if the epigastric artery is cut, as the peritoneum is undivided, the flow of blood would be immediately perceived, and then the vessel might be secured. But in neither edition of his Surgical Lectures, neither that in the Lancet of 1823-24, nor that edited by TYRRELL in 1827, does he allude to the division of the stricture without opening the sac, except in large ruptures. In both these editions of his Lectures he also expressly directs opening the sac and says in the one (a), after "feeling for the stricture,***you introduce the probe-pointed bistoury on the director or finger, and divide the stricture without cutting too much;" (p. 478.) and in the other (b), "having thus exposed the contents of the hernial sac, as far as the seat of stricture, the operator should insinuate the point of his finger or a director under the stricture, between the sac and its contents, at the upper part, carefully keeping the latter from turning over the finger or director. He should then pass the knife for dividing the stricture upon the finger or director, under the stricture, and by a gentle motion divide this stricture, &c." (pp. 44, 5.) I may also add that I have no remembrance of having seen him operate without opening the sac, in the many operations for strangulated rupture which I saw him perform in the Hospital during the first fourteen years of my professional life.

TO KEY, however, must be justly ascribed the revival of PETIT'S operation, and of its more extensive application (c). His views with regard to its employment will be seen in the following observations upon fifteen fatal cases. "The majority of the cases," he says," appeared to have died from peritoneal inflammation consequent upon the exposure of an inflamed or strangulated portion of bowel. I say exposure of the bowel; for it is, probably, not so much the wound in the peritoneal sac that disposes to inflammation, as placing the bowel under circumstances to which it has hitherto been unaccustomed. The sudden change of temperature to which it is submitted, the exposure to (a) Lancet, 1923, 24. (b) TYRRELL's Edition of Lectures, vol. iii. (e) Memoir, above cited.