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Show an, "L" *‘M s ‘W' 206 RLALONS ion cc rum; we neon or mi; sac part. If it be said, why is there now more injury done to the gut than when the taxis only was employed .9 I would an- swer, that before the incision the gut was more uniformly supported, and less exposed to injury, now the upper part of the sac is dilatabie, while the intestine is held in the neck of the sac ; and the same degree of force employed now as in the taxis, must injure the intestine. The difference in the enlarge- ment of the neck of the sac, when it is cut, and where it is distended, without incision of the sac, is, that what the knife leaves undone in the first instance, is completed by the fin» gcr or blunt hook. But, in the operation without cutting the neck of the sac, the stricture is dilated, from the compression of the gut by the hand on the lower part of the sac, distending the gut within the neck or stricture. i Wt. \m This distension of the stricture by the gut I conceive to be the objectionable and dangerous part of the operation. You know not how far you may proceed: you know not whether the difficulty be in the neck of the sac, under the stricture of the tendon which you have cut, or further up within the neck of the sac; or whether or not it be an adhesion which is preventing the return of the hernia. You use the utmost degree of force before you can ascertain whether the neck of the sac will dilate or not. It is no argument in my mind, to say-you have done your utmost before incision to return the hernia; why not now .9 The fact is acknowledged, in the circumstances of a case which comes to be cut by the knife, that the proper degree at force allowable in the operation of the taxis, has been al~ ready applied without effect. Then I find that there is a nrm stricture in one half of he cases which the promoter of this method has given us. There is even, in his estimation, an equal chance that there is a stricture in the peritoneum, which we are to try to undo by this pressure of the gut; and failing, we are to cut the neck of the sac itself. Now, when i turn my recollection to the cases from which the plates representing the bursting of the gut were taken, I remember how easily the gut is injured in the narrow sac of a hernia. coornn's oremrron on LARGE IRREDUCIBLE BERNIE. 207 when the whole force employed comes to act on that part; and in fairly considering the whole subject, I see more probability of injury than of good resulting from the proposal. Supposing, however, that in the generality of cases this method of Dr. Munro's were inadmissible, as certainly I, in dividually, conceive it to be, severe criticism must be convert~ ed into praise for ingenuity when we find practical benefit rc= sulting from the original idea. There is a kind of hernia so large, that a very great proportion of the bowels have gradually dropt down into it; and the belly with difficulty receives the returned contents of the herniary sac; and when returned, they cannot be retained. In this case, to open the sac is in a manner to lay open the belly itself; and when by indigestible food and tiatus, or congestion of any kind, or by the falling down of a new portion of the gut, a stricture takes place, where perhaps there is also an adhesion betwixt the gut and sac; then has it been found that to cut the bands of the tendon that embraces the neck of the sac, affords a relief to the contents of the sac. The stricture is taken off, and it is better tohave an increase of the hernia than to endeavour to return the contents into the belly when they cannot be retained, or to lay open the sac, into which the gut will fall down again and again, not. withstanding your utmost cares. I cannot dismiss this subject without saying a few words on the subject of peritoneal inflammation, the object of dread to Dr. Munro, from opening the sac. Dr. Munro imagined, that the peculiar danger of the opera tion for hernia, was the opening the cavity of the peritoneum, and admitting the air. Should it ever be proved that the inflammation which de» stroys the patient spreads from the cutting of the peritoneum, my reader may gather from the introduction how very dili‘er- ently I would explain the fact. But I have never seen an ap« pearanee on dissection which could give any foundation for the idea that the inflammation sp cad from the cut, or that it See Vfr. Cooper's \Votk, to whom we are Enrich";t For LU? (pen-17.037. ' wow M099?" |