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of strangulation must accompany the hernia in its reduction through the parietes, and consequently must be wholly independent of the abdominal rings, which remain unchanged in position. Examination proves, that the contracted neck of the sac is the really efficient cause of strangulation in these cases, and requires similar treatment to that which is usually adopted when a similar cause operates to the production of strangulation on a hernia descending through the rings.

The sac should, in all instances, be opened, and its neck freely divided, so as not to leave any impediment to reduction of its contents into the general peritoneal cavity. It should be recollected, also, that the adhesion of the sac to surrounding parts has been severed, and that, consequently, the sac will be liable to be again reduced, during the reduction of the contents into the abdomen, unless caution be used for its prevention. The danger of this occurrence may be always obviated by the introduction of the finger through the neck of the sac, after the contents have been reduced; for thus the fact of their perfect liberation may be readily ascertained.

Besides the events mentioned as occurring in the cases related, it occasionally, but still more rarely, happens, that the contents of a hernia are reduced into the abdomen, with the strangulation continued upon them, by other causes than the neck of the sac, the detection of which may not be facili


tated by noticing the signs suggested for the purpose during an exploring operation.

Thus the hernial contents may be so situated, that some portions may become strangulated by others, or by adhesions formed during the progress of inflammation, or by apertures of the omentum or mesentery admitting through them portions of intestine. These strangulations may take place either entirely within the abdomen, or within a hernial sac protruded from it. If in the latter situation, and the ordinary symptoms of intestinal obstruction supervene, the taxis may be applied in the usual way, and apparently at first with success, because neither the ring nor the neck of the sac, in such cases, may offer any obstacle of sufficient magnitude to prevent the passage of the tumour through the parietes. Yet, as the strangulation is caused by the involvement of the contained parts with each other, and wholly independent of the apertures through which they passed from the abdomen, their reduction is not followed by the expected relief. A certain similarity to the cases related is thus caused, and the suspicion of a reduction en masse is thus created.

The suspicion may lead to an operation of exploration of the part. But the signs of a reduction en masse before mentioned, as coming under the cognizance of the surgeon during the progress of the operation, will be found wanting ; the empty sac, with the obscurity of the chord and rings consequent upon its continued presence, becoming so

many evidences against such reduction. Neither are there any local signs from which an unequivocal opinion can be formed.

It is probable, that if the parts strangulated remain in the neighbourhood of the ring, a local and obscurely felt tumour, painful over a circumscribed space, may be discovered upon examination, especially after opening the inguinal canal. Thus may be afforded some grounds for suspecting the true nature of the case, yet not sufficiently decisive to render a section of the peritoneum anything more or less than a mere speculative proceeding, with all the contingencies of its doing good or harm to the patient's prospects of recovery.








READ MAY 9th, 1843.

Looking at disease abstractedly, I should say that no indications exceed in importance the two following, viz.:—

1. The alleviation of acute pain, whether neuralgic, spasmodic, or inflammatory, in its origin ; and

2. The securing adequate daily rest in sleep by procuring, artificially if necessary, a suspension at least of any morbid actions or conditions that might militate against refreshing repose. Almost all the suffering, and great part of the danger, of sickness may be referred to uneasy sensations of one sort or other, the irritated nervous tissues re-acting throughout the economy on the nutrient functions,

deranging the elementary affinities in the blood, undermining the organic powers, and ultimately ruining the general health. Looking again at disease as we see it in clinical practice, there are no medicinal substances of more interest or importance in its treatment than such as are fitted to fulfil these two indications. In the records of medicine there are few results of professional research more striking than the beneficial effects obtained from opium in various diseases.

Satisfactory effects have also been obtained from other agents in our pharmacopoeia, of the narcotic class, especially henbane, camphor, prussic acid, belladonna, aconite, &c., in allaying neuralgic pain, or checking spasm, or procuring sleep. But of all our direct anodynes, antispasmodics and hypnotics, opium is undoubtedly that one popularly known in England as the principal, the most powerful, the most certain, and in a word as fairly worth at least all the rest.

But the use of opium has many inconveniences that limit its application very much, so that in cases standing greatly in need of that ease and repose which, under favourable circumstances, opium is so well calculated to yield, we are not unfrequently prevented from employing it. Its tendency is to produce torpor in the stomach and bowels, and to stop the digestive process and the peristaltic actions; and thus to cause anorexia, constipation and active indigestion; it deranges the hepatic and renal secretions as well as those of the mucous linings of the

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