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Show 2204: Issues nor THE manor cause or sl'nanovtanon; the neck of the hernia, and cause strangulation. But when a hernia remains down, and the economy of the included THE original Munro had proposed, in cases of strangulated hernia, with adhesion to the sac, to relieve the stricture merely, The parts within the stricture are the peritoneum, and surrounding cellular membrane, and the gut or omentum, included in the peritoneal sac. How the former will be strangulated independent of any change in the sac, I have already described, But let us observe how a stricture of another kind, be it. 14mm y ..... A MORE PARTICULAR INQUIRY INTO DR. MUNRO'S PROPOSAL OF still say that these tendons form the stricture, yet are they in which is the cause of the incarceration and strangulation. animus w a c 20:} portion remains for a time perfect, the strangulation which may afterwards take place arises from other circumstances than the tendons surrounding the sac; and although we may passive only. They are as wide as they were; nay often, as I have said, dilated. It is the swelling of the parts with- _ ii em ‘ ‘ 4... DR. MUNRo's rnorossn TO CUT Tim TENDON ONLY. the omentum, or the adhesion of the intestines, or strings of coagulable lymph formed betwixt any of the bowels, become thick and inflame, in consequence of the strangulation of the gut, and we shall conceive how an incarcerated hernia produces a reciprocal influence betwixt the gut and the perito~ ncal sac; and that while the former is irreparably injm‘Cd, the latter becomes thickened, and its attached cellular mem- brane distended by the infiltration of coagulable lymph. It is this condensed matter of the neck of the sac which must be cut through in hernia, in nineteen of twenty cases, or else an undue and a dangerous degree of force must be used to distend it, by compressing the lower part of the 001i volution of gut which is contained in the hernia. It is alleged, that if we can disengage the hernia by means of" cutting the tendons on the outside of the gut, without piercing the sac or peritoneum, it may be done very freely» This 15 precisely what I object to. You cut freely the tendons of the muscles, the only support of the bowels in in: tnre ; while in cutting the sac and tendon, you out very little of the latter, and the neck of the sac is consolidated in the c77Cairix, if the tendon does not unite. OPERATING BY CUTTING THE TENDON ONLY. and to allow the parts to remain. His son, in his work on the Bursa: Mucosce proceeding upon the acknowledged principle, that sacs and cavities, when opened, were prone to run into universal and dangerous inflammation, proposed to relieve the stricture of the tendon, and to return the bowels without divid ing the sac. This Dr. Munro at the same time acknowledged was a proposal of Petit only, observing thdt he mistook the principle on which the operation should have been done. In his first case, with Mr. Alexander Wood, a case ofcrurai hernia, they cut the tendon, and then reduced the hernia with. the utmost case. In the next case (of hernia congenita), they found the neck of the sac contracted, and requiring to be out. In another, a large hernia, by cutting the tendon, the bowels were reduced. In the fourth instance, they found it necessary, after cutting the tendon, to puncture the sac, and cut its neck. On this proposal, and these original cases, I would remark, that it is an error to conceive that first cutting the tendon, and then trying to reduce the hernia, is a harmless operation; and, if not successful, may be followed by the incision of the neck of the sac. For to free the stricture of the tendon requires a very free cut ; and to have after this to cut the sac, makes the whole incision too large. I have always observed, that when the cause of the stricture was mistaken, the incision of the tendon was particularly large, as in the plate, where I have represented the epigastric artery cut. Now here the surgeon cannot say, until he has cut very freely, whether he has out enough or not; for the difficulty may be in the sac. Further, to compress the sac so as to dilate its neck, must be dangerous to the already constricted and injured gut at that ' new Minn" :' |
