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Show 19:12 or CUTTING Till: srmcrnnn. minal ring, his finger being still a director to the knife. ()F CUTTING THE STRICTURE. Thug he carries the knife along the fore part of the sac, until he in- sinuates it under the stricture formed by the lower edge of the transversalis and internal oblique muscles ; and then turn« ing the edge of the knife forward by a gentle motion of its handle he divides the stricture sufficiently to allow the finger to slip into the abdomen. The direction in which this strict« ure is divided, is straight upwards, and opposite to the incie ion of the outer tendon. I cannot help expressing my conviction of this being a very difficult operation ; for either the muscle has firmly embraced the peritoneum, still of its natural tenuity and elasticity, or the membrane has inflamed under the pressure, and is thickened. If the first supposition be the true one, then will it be difficult to force a probe-pointed history under the edge of the muscle ; a sharp one would pierce the peritoneum ; and if the membrane is thickened, the sac w ill resist after the tendon or mus. 1'1""le 11m" . tikthklflm cle is fully cut. Further, if the stricture which we feel be the natural embracing of the parts, then, be the fibres tendinous or muscular, a strong directory, introduced over the mouth of the sac, will tear up or stretch them so that the knife is not required in these dangerous depths ; and if, as I think I have ascertained in most cases, there is a general thickening of the sac, or of its surrounding cellular membrane, this deep dissection on the outside of the sac will not be sufficient to undo the stricture, without the force of the finger within the neck of the sac. That in several cases the stricture is in the sac (as in the instance I have engraved), cannot be doubted. I suspect that the sac, in all cases above a few days standing, is more or less condensed, and that when inflammation or compresé‘iO" has been for any considerable time, although the stricture may have originally been on the outside of it, it is no longer en' S‘ireiy . if the point of the finger bolts up against a thickened and entire ring, it is a stricture which encircles the neck of the sac, rind should be cut from within the sac ; for if it entirely €11"irrles the neck of the sac, it no stricture from the margi" 19;: of a. muscle or tendon. Were the stricture from the margin of the muscle, there would only be a corded feeling on the up: per side of the neck of the sac. All incisions of the neck of the herniary sac are to be made directly upwards. This is the manner which the mere cons venience would point out ; and when we consider the thing more deeply, we find that the epigastric artery may be cut by too adventurous an incision. The epigastric artery mounts in general on the back and inner side of the neck of the sac ; and even when in this more common relation to the hernia, by too long an incision it may be cut, as I have seen happen. But sometimes (as when the hernia comes down nearer the pubes), the epigastric artery rises on the outside of the sac, and turns round it to rise upon the belly; so that if we cut freely outwardly and upward, we must open it there. Lastly, the epigastric artery, sometimes rising on the out: side of the neck of the hernia, gives 011' the obturator artery -, and this last clinging round the neck of the sac, descends again into the pelvis; so that an incision in any direction would here meet the artery! This, though I could give a drawing of it, from my own experience, I fancy must be rare. Notwithstanding these apparent difficulties, in regard to the course of the epigastric artery, little mischief has resulted in the operation. The danger, however, is still so far a possibility, that it leaves an unpleasant impression on the surgeon's mind during operation. There is scarcely a possibility oi. our cutting this artery, if the history is raised like a lever on the finger, so as to cut only what strongly resists, not the softer and yieldii g parts. I believe the epigastric artery has been cut, when surgeons have mistaken the cause of the difficulty in returning the gut, and have cut to a much greater extent than was necessary. I have seen this artery cut fairly across, and yet very litth: blood escaped, which I could not account for. Mr. Sharpe Supposed it easy to take it up with a needle, if cut. 1 shouts; wam mosh/i, Ii |