cent appearance of the vessels on its surface; but not infrequently the operator is in doubt whether he has reached it or not.

and moves freely, then we are sure

Two procedures help to dispel this. First, attempt to draw the supposed sac downward a little. If it is sac, it will yield to tension, at least to a certain degree; if not, we shall find the tissues are continuous with the abdominal parietes. Again Pass a probe along the supposed sac. If it enters a cavity that we have reached the sac-wall. fluid in the cavity when opened. there is fluid outside of the sac. sac. The rule, however, is that, This may be little or much. The amount is often so large as to cause astonishment.

Another guide is the presence of This is not constant. Sometimes Sometimes there is no fluid in the when the sac is opened, fluid escapes.

If there is any doubt even at this point, it will be solved by the smooth shining surface of the interior of the sac, which is so characteristic of peritonæum.

The sac being open and the gut disclosed, the questions of replacing it in the abdominal cavity, or of leaving it in the sac when it cannot be reduced, or of resecting it when gangrenous, or of making an artificial anus at this point, are among those to be decided, but involve the discussion of surgical principles which would exceed the limits of this paper, even if they belonged properly in this place.

The constriction must next be relieved. It seems easy in theory to determine what causes it, as the parts are all exposed. In practice it is often difficult, and may at times be impossible, to be sure,

In femoral hernia, it may be Hey's ligament, it may be the crural ring, it may be in the neck of the sac itself; in inguinal hernia, it may be conjoined tendon, it may be the infundibuliform fascia between the external and internal rings or at the internal ring, it may be at the external ring, it may be (and often is) in the neck of the sac itself: whatever it is, it must be searched for and relieved. The direction of the relieving incision has already been discussed in speaking of the landmarks,

The disposition of the sac after reduction of the intestine; the disposition of the intestine itself when anything more than simple relief of the stricture and reduction is necessary; the disposition of omentum found in the sac,-all these questions will be considered in another division of the subject.

Two or three points more, and I am done.

The patient may be in good condition; the gut may be in good condition to return to its cavity, but the swelling and tension so great that reduction is impossible, even after enlarging the constriction as much as is deemed safe. In such a case it is good surgery to make an

opening into the intestine and allow its contents to escape, being careful to direct them away from the wound, or at least first to carefully protect the wound from contact. This will relieve tension sufficiently to allow of reduction in almost every case. The small opening in the gut, when carefully closed by the Lembert suture, does not prove prejudicial to the success of the operation.

Adhesions often are found between sac and intestine or between omentum and intestine. These must be carefully separated by the fingers or some blunt instrument. Intestine and omentum should

always be separated.

In cases of threatened gangrene of the gut, it is sometimes admissable to allow adhesions to remain, particularly those near the neck of the sac, as they tend to form a barrier to the admission of any foreign substance into the abdominal cavity in the event of the gut giving way.

Great care is to be taken to guard against admitting any foreign substance into the abdominal cavity. When this threatens, protect the opening by an antiseptic sponge or plug of iodoform gauze.

ber that the cord lies behind the sac in inguinal hernia. Both this and the gut are liable to be injured by careless incisions. Every cut, after the original opening in the skin, should be made on a grooved. director.

Lastly Be careful not to disturb the testicle from its situation in the scrotum; and, in case it is disturbed by being drawn up with the sac, do not try to reduce it with the hernia. This may seem a foolish piece of advice. Still the cord is often firmly attached to the sac by adhesions, and, during the necessary manipulations, the testicle may easily be drawn out of the scrotum and appear in the wound. I once saw a distinguished surgeon, while operating before a class of students, make persistent efforts to reduce a testicle which had been drawn up with the cord and sac. It was not until his house-surgeon-now a well-known professor of surgery-called his attention to what he was trying to do that he desisted, and, returning the testicle to the scro'um, informed the class that the adhesions had at last all been overcome, and that the hernia was successfully reduced. This announcement was followed by applause.

SOME POINTS ON THE REDUCTION OF HERNIA.

BY J. S. WIGHT, M. D,

Professor of Operative and Clinical Surgery at the Long Island College Hospital.

Read before the Medical Society of the County of Kings, October 15, 1889.

The part of the surgical report assigned me by the committee relates to the reduction of hernia. And by this I understand that I am to consider the practical question of reducing some part of a viscus

that has protruded from an abnormal opening.

And as this question

is a very broad one and cannot be fully considered in one part of a single report, I am obliged to limit my remarks to Some Points on the Reduction of Hernia.

In the first place the question of diagnosis lies at the bottom of the question of reduction of hernia. How could the surgeon reduce a femoral hernia, when he is under the impression that he has an inguinal hernia? How could he reduce an oblique hernia when he has made a diagnosis of direct hernia? On more than one occasion I have been asked to assist in operating for inguinal hernia and have easily reduced a femoral hernia. It is evident, therefore, that a mistake in diagnosis does not prove that a hernia is irreducible. It only proves that the surgeon, who makes a mistake in diagnosis, cannot reduce the hernia which he is called to treat.

A correct diagnosis largely depends on the following facts: 1. The surgeon must have a complete knowledge of the anatomy of the regions where hernia occurs. There is no need of any argument or

2. The surgeon must be thor

illustration to prove this proposition. oughly informed in regard to the pathology that results in connection with hernia. If he is ignorant on the pathology of hernia he cannot make a correct diagnosis. 3. And then it must follow that the surgeon must have experience. He must have had much practical observation and study of the signs and symptoms of hernia, Without practical knowledge the surgeon will often fail to make a correct diagnosis of hernia.

Has

Has it

In the meantime several other practical questions may arise. the hernia just appeared, or is it an ancient dislocation? existed a few hours, or a few days? Is it large or small? Does it contain omentum or intestine? Or does it contain both intestine and omentum? Is there adhesion or obstruction? Or have we an obstruction following more or less adhesion? Is there strangulation, with or without gangrene? Is there inflammation accompanied by the formation of pus? Has the hernia been in existence a long time, so that adhesions have formed, making reduction impossible? Is the abnormal opening large or small? All these questions have a praetical bearing on the reduction of hernia, and may be raised by the surgeon before he makes taxis.

up in many cases of It is often necessary

And then the question of operation comes hernia, and must be considered by the surgeon. to make preparations for an operation before we attempt to reduce a hernia. The operation is made in order that the dislocated intestine can be reduced. If the patient survives and a radical cure can be effected, the surgeon will have done good work. The question of rad

ical cure follows the successful attempt to cut down and accomplish reduction. Our opinion at present is that the surgeon ought to reduce a hernia, if he can, and then subsequently operate for a radical cure. But the question for us now to consider is that of reduction.

I need not now review the points which relate to the position of the body and limbs of a patient who has a hernia to be reduced. Let me give a description of the method of taxis which has been very effectire in my practice for many years—a method that has prevented more than one operation, and diminished the number of irreducible herniæ.

Grasp the hernial tumor with the right hand, and then make gentle traction; the hand compresses the hernia and its contents, and liberates the neck of the sac in the constricting canal. And then two effects may follow: Some of the contents of the sac are expressed into the abdominal cavity. This may be the contents of the intestine-the special fluid of the sac, or the intestine itself, especially if it is not adherent to the sac; or the sac and its contents may begin to be reduced. The surgeon cannot make this gentle traction without compression, and the compression tends to expel the contents of the sac, as well as the sac, when it has not formed adhesions to the tissues around it. And what is more, the gentle traction tends to straighten out that part of the hernia just external to the canal that contains the neck, and the effect of this is to remove the folds which overlap and prevent successful reduction. And then another expedient may be put in operation. The thumb and fingers of the left hand may grasp the parts of the hernial tumor just external to its exit from the abnormal opening, and this for two purposes: one, to prevent the hernial sac from folding over, and, as it were, away from the hernial canal; the other, to guide the hernia more directly to the external opening of this canal. And when these purposes are accomplished, such traction as we have made may cease, and then more or less firm pressure with the right hand may be made in such a direction as to cause the hernia and its contents to move toward the opening whence it came. The hold of the constricting tissues has to be loosened by gentle traction; some of the hernia may have been reduced; the folds of the sac have been removed; the thumb and fingers of the left hand guide the hernia toward its exit; the reasonably firm pressure induces more and more of the hernia to return to the abdominal cavity; and finally the reduction is complete, and the patient is relieved of pain and distress.

Generally such a result can be obtained without an anesthetic. In a few cases I have employed an anesthetic, mostly in sensitive patients. In the first place, I make a reasonable effort to reduce a hernia, and then, on failure, I give an anesthetic; and if I do not succeed then, I operate. And the great majority of cases of hernia which I have been

called to see I have reduced without an anesthetic, and by the method above described. I urgently recommend this method, and I have tried to induce others to adopt it; in fact, I have tried to teach it to others.

It need not be urged that a hernia is sometimes irreducible. We have been considering a hernia that can be reduced, and we simply say that such a hernia can be most readily and surely reduced by the method we have above described. Of course a real irreducible hernia requires an operation, and the sooner the better.

And I cannot conclude my very brief report without adding a few facts of observation. It has often happened that a doctor has been called to a patient who has had a hernia, strangulated or not, as the case may be.. He has not succeeded in reducing it, and has advised an operation, directing that the patient should be taken to the hospital. The conveyance carrying the patient has been driven over the streets of this city, and when the surgeon finds the patient in the hospital he can easily reduce the hernia. This success is not always due to the skill of the visiting surgeon. In the meantime the patient has been well shaken up by the drive over the rough stony pavement; in fact, the hernia has also been shaken up, and the grasp of the constricting structures has been loosened, so that reduction is easily accomplished.

DISCUSSION.

Dr. FOWLER.—In order to demonstrate the cicatricial plug which occupies the site of the canal after McBurney's operation, I brought two of the patients here to-night upon whom this is well shown.

The first is a man of fifty, who had suffered from inguinal hernia for about thirty years, and who about three and a half years ago, in Stockholm, had an operation performed for a radical cure, which consisted in ligating the neck of the sac and drawing together the pillars of the canal and the edges of the skin.

The second patient is a female, age forty, who was admitted to the hospital with a strangulated hernia of three days standing. The hernia was of the inguinal variety, and had existed for upwards of fifteen years. No truss had ever been worn.

The usual operation for strangulated hernia was performed, and this was supplemented by the operation of radical cure after the manner of McBurney. The gut was found in an exceedingly threatening condition, and it was only after waiting for a half hour following the relief of the constriction that I decided to return it to the abdominal cavity. The patient did not thereafter give us the slightest occasion. for uneasiness, and at the end of the customary six weeks walked out of the hospital a well woman.