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Show 193 or CUTTING Tn}: STRICTURE. or CUTTING "rue sa-nlcrvnn, In this part of the operation, the directory, 1, lies along the finger. The history, 2, is introduced along it. But now we do not cut with a sawing motion of the instrument, but merely by raising it (as from 2 to 3). By this means only, the strongly resisting parts of the tendon are cut. The edge of the knife is directed across the fibre of the ten» don, upwards, neither inclining to the pubes nor to the haunch. The finger now foflows the directory, and enters the stricture, or passing it through what appeared to be the chief strio ture, another, the firm inner margin of the neck of the sac, may be felt strongly embracing the gut, where it comes first from the cavity of the abdomen. This inner stricture is to be cut like the last, the assistant holding up the ring with the blunt hook, and guarding the intestine below. 1‘); As to the abdomen being afterwards more easily closed, it is still a question. The tendon requires to be cut very freely to allow of the dilatation of the neck of the sac, inflamed and condensed by the continued pressure. 'We need not now saV that as the cause of hernia. is originally in the deficiency of the tendons, or some malconformation, so will the hernia be particularly apt to recur wherever these tendons are cut ere tensively. Further, when the neck of the sac is cut, it readily adheres, or the inflammation condenses and gives lirmness to the cicatriX ; but when the neck of the sac is not cut, we can= not expect adhesion or contraction of it so readily to occur. The only question that remains in my mind is, whether will the inflammation of the peritoneum of the general cavity of the abdomen be more apt to follow when the mouth of the sac is cut, than when the cut is carried within an inch of it P On this point I should wish to have more facts from dissec- Of THE DIRECTION OF THE INCISION OF THE RING, AND OF THE vomit/"sum. tannin! PROPRIETY OF CUTTING THE RING \VITHOUT THE NECK 02‘ THE SAC. 4 . "gout-ea,» --~ 1 Mn. Coornn says, it is best to divide the stricture, by pass« ing the knife between the ring 31nd the sac, as a larger portion of the peritoneum is thus left uncut, and the cavity of the ab« domen is afterwards more easily closed. In many cases, this is not practicable; and in the general question, the propriety I think is doubtful. It must be Vcl‘y difficult to do this» when the stricture is narrow, and the distension of the intess tine included in the hernia great. It must be difficult to dissect the tendinous circles which are around the neck of the tion of the parts after unsuccessful operation. But of all that I have hitherto dissected, the inllannnation did not spread from the cut of the mouth of the sac, along the surface of the peritoneum. The inflammation evidently had its origin in the intestine. The stricture higher in the neck of the sac-is, Mr. Cooper imagines is produced by the pressure of the transversalis mussic of the abdomen ; and he recommends the following manner of cutting it. The surgeon passes his finger up the sac, and through the abdominal ring, until he meets with the stricture. He then introduces the probe-pointed bistory, with its flat side toward-2 the linger, but before the sac, and between it and the abd0< sac, from the sac itself; and when this is done, the sac will «ca-.5: . ~- ._.L,. ,.. .4 still resist in a degree which requires the forcible introduc~ tion of the finger, and endangers the intestine. recollected, that no cutting of the ring, in hernia, would be required, were we at bore and stretch the mouth of the sac. my judgment, this forcing of the mouth of danger to the intestine It will be nine of ten cases of liberty forcibly to But to the best of of the sac, is full " This stricture, high and in the mouth of the sac, lhavc long known, 3.3 may be seen in my l)isscctions.-" I have found, in operating on the in-‘ gninnl hernia, that the constriction was not in the ring, but in the peritoneal sac, fully two inches within it ; and in the case to which I allude, the stran- gulation was so complete that the gut was gungrencd." Appendix, page 5 thiscs occurring since have confirmed me in the opinion, that this internal are is in the peritoneum, and surrounding cellular membrane, more . .1 the tendons or muscular librcs. ,, c: , VlUNl M0 |