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peritoneum section, have been removed, by its obvious necessity being clearly demonstrated.
In conducting operations of exploration, it therefore becomes very desirable, that great attention should be given to such indications as our incisions make available to our use, so that by the aggregate of these, our diagnosis may, if possible, be made clear, before we arrive at the peritoneal surface.
The indications which are to be sought for, are, for the most part, of a similar nature to those already mentioned, as useful in the manual examination. They are, however, more satisfactory and distinct, inasmuch as the parts to be examined are, by our incisions, brought immediately into view, and are not obscured by the interpositions of superjacent structures. Thus, by the perfect exposure of the external inguinal ring, which the cutaneous incision affords, the size of the aperture, together with the extent to which it is occupied by structures passing through it, are clearly made manifest, and the same inferences drawn from the observance of these particulars, as suggested in the mere manual examination. For if the size of the ring be normal, a hernia has not descended through it ; or, if it be larger than the normal state, yet occupied by an empty sac, an evidence of the previous existence of a hernia, together with an evidence of the reduction of the hernia without the sac being also reduced, is established. But should the ring be found large, and free from other structures than the chord, and if the chord be distinct and unobscured by the presence
of sac, and a void is found where fullness is to be expected from the previous history of the case, a strong presumptive evidence on the contrary side is established, that the hernia, together with its investing sac, is reduced.
In proceeding with the exploration, the inguinal canal is next laid open. It has been observed, that no information of a useful character can be obtained by external examination of this part, unless a tumour be present within it; but the exposure of the contents of the canal by incision, by adding ocular to tangible examination, renders this proceeding most valuable. The indications to be found here may be expected to be of a decisive character, and I believe that the surgeon generally will not be disappointed in his expectations, and on that account I hold a close observance of the condition of parts within the canal to be a matter of very great importance.
It will be recollected that the ordinary oblique inguinal hernia, during its passage through the canal, lies anterior to the spermatic chord. The hernial sac, when left empty after the reduction of its contents, occupies the same relative situation, and consequently overlays and obscures the chord after the canal is laid open. If the reverse of this is found in a case where a hernial descent is known to have previously existed, and the chord is ascertained to be clearly and distinctly brought into view throughout the whole extent of the canal, we may justly conclude that the distinctness and clearness with
which the chord is seen are caused by the removal and consequent reduction of the hernial sac from over it, which reduction can be effected in no other direction than into the abdomen.
Again, it is well known to all operators on strangulated hernia, that there is usually found a condensed cellular capsule immediately investing the sac, which, in the performance of an operation, assumes a laminated appearance, and often passes for layers of fascia. This cellular capsule has but little connection with the sac, and will remain even when the sac has been reduced. It will, therefore, be worth while to seek for such capsule in our explorations; for, if found, and ascertained to be empty, the circumstance is of a very conclusive character, and moreover will afford a direct clue to the situation of the hernia.
A finger, introduced through an opening made in such capsule, will be conducted towards or through the internal ring, beyond which it will be brought into contact with the hernial tumour itself, having in the introduction passed through the same channel by which the reduction was effected. It must not be expected that such capsule will be found in all cases, because it might escape notice by reason of its tenuity, or, in reductions of some duration before the performance of operation, adhesions and obliteration may be caused by inflammation ; yet when found, it is a most valuable adjunct to the other means of diagnosis.
The indications to be noticed at the internal are
of a similar nature to those mentioned as being found at the external ring, and relate to the size of the aperture and the structures by which it is occupied. With reference to its size, it may generally be expected to be abnormally large, because before proceeding to perform an exploring operation, there will probably be some account received of a hernial descent having occurred, which descent necessarily implies that it has passed below this ring, and consequently through it. For that reason, the ring may be expected to be large, and its borders defined; while its area will or will not be occupied by hernial sac, and the same conclusions drawn from the particular ascertained, as from the same occurrence at the external ring.
It will be observed, that up to this period the proceedings of the exploration have been conducted without any danger of importance, and without any necessary disturbance to the peritoneum, vet information of the most conclusive kind may have been obtained, and such circumstances brought under notice as would fully justify the operation, even if manifold more hazardous than it really is.
It may be admitted, that the whole of the above particulars merely tend to raise a presumption more or less forcible according to the clearness of the evidence which they afford. But the operation may be conducted to a demonstrative conclusion, by ascertaining the existence or non-existence of a hernial tumour, without adding materially to the trifling danger already incurred. This is accomplished simply by the introduction of the finger through the internal ring, and by passing it from side to side. Should a hernial tumour be present, it will at once be recognized, and found lying externally to the general peritoneal membrane, although within the parietes, and presenting a rounded surface and tense feel. Should a tumour be not present, the circumstance may be ascertained by observing the smooth surface of the peritoneum, and the continued adhesions which it maintains with the parietes immediately surrounding the ring.
If doubt still exists, an enlargement of the internal ring, by division of the adjoining transversalis fascia, will afford a clearer exposition of parts, and a more decisive evidence for either an affirmative or a negative conclusion; and thus an exploration may be conducted to its termination, without the necessity of any peritoneal section.
When the doubts have been resolved in the affirmative, by the discovery of a hernial tumour, the tumour may be brought into the inguinal canal, so as to occupy its former situation before reduction, by enlarging the ring to the requisite extent for its passage. It may afterwards be opened, and its contents dealt with according to their condition, as under the ordinary circumstances of common operations.
At this period, the contingencies necessary for the reduction en masse should be called to mind, for they will influence the steps of the operation at this stage. Thus it should be recollected, that the cause