reducible ruptures which have suddenly descended, producing symptoms of ileus, are without doubt caused by a stricture, but all large and irreducible herniæ, which have for some time previously caused pain, particularly after meals, and have produced occasional obstructions in the bowels, are most probably connected with adhesions. The tumour is also generally less tense, and the abdomen not so soon painful in cases of obstruction, as of strangulation; but these distinctions are not immediately necessary, if a surgeon bears in mind the necessity of separating any adhesions which he may find, in cases where he has occasion to operate for hernia, and of not considering the stricture as the only possible cause of the symptoms.

So much for our author's views of what he denominates "obstructed hernia," and we believe that we have given the pith and marrow of them. No doubt can exist, nor indeed has at any time existed that bowels confined by adhesions in hernial sacs, will not go on with their natural functions so freely as when loose and floating in their native cavity. But the question is, will adhesions, per se, occasion a fatal obstruction to the office of the gut? Mr. Stephens says they will; and the issue is with him and his surgical brethren. For our own parts, we doubt whether such be the case, nor can we imagine that a patient will die from this cause alone. The case is very different when the adhesions are so arranged as to act like a stricture in the gut, or when the latter is so placed as by being convoluted in itself, or in any other manner to prevent the egress of matters from its cavity. We also doubt very much the propriety of the practice recommended by Mr. Stephens, of always dividing the adhesions in the operation for strangulated hernia, and particularly of dissecting, as it were, one fold of gut from the other. Who has not seen adherent intestine left in the sac after the operation of dividing the stricture, and that without any bad results whatever? He would be a bold surgeon, we think, who, in operating for old irreducible hernia, was to make it a rule to return the parts, no matter how firm the adhesions were! Whilst we profess ourselves not to be convinced then by our author's reasoning, we award him gladly the meed of ingenuity, zeal, and industry in collecting the facts with which he has flanked his opinions. We must say too, and we do it sincerely, that Mr. Stephens has at all events placed in a stronger point of view than is usually done, the inconveniences, if not dangers, of adherent hernia.

Our author next proceeds to the consideration of INFLAMED HERNIA, and although we by no means agree in much that he advances, we cannot but admire the dexterity with which he brings forward other peoples' cases to support his views. Having shown, or attempted to show, that adhesions of the gut are a source of obstruction to the right performance of its functions, he conceives that they are also a frequent cause of inflammation.

"The contents of a rupture are said sometimes to become inflamed in connexion with an inflammation of the bowels generally, and totally independent of any cause arising from the rupture. That this may sometimes be the case is probable, but I believe such instances are extremely rare. These inflammations, I believe, are almost always generated by the morbid condition of the parts within the rupture, and afterwards becomes quickly communicated to the interior of the abdomen. Large irreducible herniæ, more especially umbilical, are those in which this form of disease mostly occur, which appears to partake more of the character of enteritis, than of ileus. A small portion of confired intestine, however intensely inflamed in itself, does not so necessarily, or so quickly VOL. XI. No. 21.

16

communicate its disease throughout the abdomen, it being of comparatively local origin; but when the contents of a large hernia become inflamed, as a sequel (I believe, of various chronic confinements, and changes of structure of the parts, the disease from the first will be of a more diffused and general character, and will more extensively and quickly communicate with the interior.

"Although large irreducible ruptures are those in which disease and inflammation, independent of mere mechanical obstruction, are most likely to arise, yet small irreducible ruptures are also very subject to this form of complaint, particularly omental, or those wherein omentum is contained. The omentum is subject, in its unnatural situation, to become thickened and diseased, and to suppurate.* The hernial sac will also often inflame and suppurate. The appendicula epiploca of the colon will also occasionally undergo some alteration of structure, when confined within a hernial sac. All these various changes and states of disease become a frequent source of inflammation to the contiguous bowels or peritoneum. The inflammation which is thus produced is attended by an obstinate obstruction, and symptoms of general inflammation throughout the abdomen, and is generally fatal in its consequences. When these herniæ are small, the inflammation of the rupture denoted by pain, soreness, and tension of the part, so clearly precedes the inflammation of the abdomen, that the case is usually mistaken for strangulated hernia, and if an operation is performed, the tension which the parts have acquired fills up the opening through which they have descended, and favours the mistaken opinion of the existence of a stricture. When the herniæ are large, the inflammation of the abdomen and of the hernia are very often nearly simultaneous, and if upon operating there is found a palpable absence of stricture, then the hernia is supposed to be merely participating in a general inflammation of the intestines. The want of success attending operations upon large herniæ, particularly umbilical, is attributed to the direct exposure of the peritoneal cavity, by which a dangerous inflammation is excited. I believe that the inflammation which destroys the patient is, in the majority of cases, altogether established before any operation is attempted.

"Cases of unsuccessful operation for hernia are, in my opinion, very frequently cases of the above kind. If omentum has formed a portion of the hernia,† it is generally found upon dissection to be in a state of suppuration, adhesion, or thickening. Considerable inflammation is usually found to have prevailed throughout the abdominal cavity, and herein consists one strong feature of distinction between inflamed and strangulated hernia. In inflamed hernia, the peritoneum and intestines are found inflamed throughout. Layers of coagulable lymph, and depôts of pus, are interposed between the convolutions of intestine, both above and below the part forming the hernia. In strangulated hernia, after death, according to Sir A. Cooper, page 29, Part 1st. ‘three or four convolutions of intestine are found lying across the abdomen, so enormously distended as to exclude the other viscera from view, and agglutinated slightly together by an effusion of adhesive matter; the track of adhesion is formed by red lines,' &c. and further, 'the portion of intestine below the stricture, is, on the contrary, remarkably contracted in diameter, and free from any appearance of inflammation."" 71.

With regard to the diagnosis of inflamed herniæ, our author remarks,

that

"It may be distinguished from a strangulation of such parts, by the more gradual

"In old irreducible hernia the omentum often becomes diseased."--Sir Astley Cooper, page 27, Part 1st.

+ Sir Astley Cooper says, page 30, Part 2nd, "I have never seen the umbilical hernia in the adult but that it contained omentum."

approach of the symptoms, and by their less degree of violence. From obstructed hernia from adhesion it is to be distinguished by the pain and tenderness of the parts generally preceding the obstruction, and by there being more decided marks of an inflammation existing Pain. with inflammation throughout the abdomen, is generally soon manifested in inflamed hernia, whereas, in obstructed hernia, it is a late symptom, and in general, scarce ly prevails at all Obstructed hernia may possibly be followed quickly by inflammation, and then it would become altogether as a case of inflamed hernia, and require an earlier operation.

"In inflamed hernia, the viscera of the abdomen are very extensively inflamed throughout. In obstructed hernia, very slight traces of inflammation are in general visible after death. Cases of strangulation, are of an intermediate kind; the inflammation being almost wholly confined to the seat of stricture, and the parts above it; the intestines below being in a state of collapse, and uninflamed."

"An empty hernial sac is not unfrequently, by becoming thickened and diseased, a source of inflammation to the bowels and peritoneum; but I have reason to believe that the inflammation so produced is not generally so extensive or so fatal as when intestine is contained within. Coagulated lymph, or pus, forms within the sac. If the former, adhesive inflammation only has prevailed, and the patient will not unfrequently recover. pus has formed, the case is more dangerous. An operation appears to do good, by giving exit to any pus or fluid which has been secreted." 90.

When

The chapter on the Treatment of Hernia we must pass over, as it contains scarcely any thing that has not already been advanced by Mr Stephens in his Observations on Obstructed and Inflamed Herniæ. A suggestion for the radical cure of the disease is too curious to be dealt with in so summary a manner. We find it quite impossible to analyse the work, and contrary to our usual custom we are constrained to indulge in longer extracts than we could wish. The following will describe the operation proposed by our adventurous author.

"A friend of mine, had a favourite and very valuable pointer bitch, the subject of a very unsightly and enormous hernia, which from its great size and weight, rendered the animal nearly useless, and her owner had considered the propriety of destroying her. I begged to be allowed to try the effects of an operation to return, and retain, the protruded bowels in the abdomen From the time the hernia had existed, and from its very large size, I had great doubts of success. I began by reducing the condition of the animal, as I foresaw that the less superfluous fat there was upon the omentum, and in the interior of the abdomen, the greater was the chance of success in returning and retaining the parts. When she was sufficiently reduced, I began the operation by feeling for the opening through which the intestines protruded from the abdomen; upon distinctly feeling this, which was in the situation of the inguinal ring, I began the incision directly over it, carrying it about half way down the surface of the tumour, and through the integuments. I then cut through a quantity of fine cellular structure, and opened the hernial sac, and found omentum and intestines within. I began immediately to draw the parts up from the bottom of the tumour, and to push them with my finger through the opening into the abdomen, but I found there was one considerable portion which I could not reduce, owing to its strong adhesions below. Having always been able apparently to return the hernia, I was surprised to find it irreducible, but it seems, it was the omentum and one portion of intestine only, which was returnable, another portion, being firmly connected to the parts out of the abdomen, had never admitted of reduction. I however proceeded by inverting the hernial tumour by which means I could see the whole irreducible part of the intestine, without the necessity of laying the sac open to the bottom; this discovered to me that the

bowel was not simply adhering to the hernial sac, but that its coats were absolutely incorporated with it, having no line of separation. To attempt in this case to dissect the bowel away from the sac, would have been at a very considerable risk of wounding it; but it occurred to me, that I could separate the sac from the integuments, &c. forming the hernial pouch, to which it had become closely joined In this I succeeded, and returned the intestine and sac into the abdomen, adhering as I found them. The opening from the abdomen was so considerable, that unless my finger was almost constantly there, I could not prevent the parts from again protruding. The difficulty now, was to retain the bowel within the abdomen. A bandage was of no use, and my object was to gain a radical cure by effectually closing the abdominal opening. I succeeded in preventing the parts from protruding, by means of the quilled suture, substituting pieces of wood for quills; these being drawn closely over the opening, prevented any immediate descent of the hernia, but I saw clearly that the purpose of the operation could not in this way be fulfilled, for the abdomina! opening could not be closed by means of the integuments, which would necessarily unite anterior to, and not over the ring, and therefore, the intestines might again force their way beneath them into the cellular structure. However, the immediate return of the hernia was prevented by it, but I must confess, I had but few hopes of its ultimate success. I finished, by closing the remaining part of the wound by sutures The pressure of the quilled suture upon the vessels of the thigh, obstructed the passage of the returning blood, and caused oedematous swelling to some extent in one limb; I relieved this by incisions, and at the end of about four or five days, removed the sticks and ligatures. The removal of the sutures relieved the swelling, and the animal recovered rapidly. Some physic which I gave her, operated freely, without occasioning any disposition in the parts to return. The operation was performed in August, and the bitch was used during the shooting season of September and October, and proved equal to any exertion that was required. Having subsequently removed the pouch which contained the protruded bowels, no trace of the deformity remained. I had the satisfaction of seeing my canine patient perform her duties with alacrity and vigour; and of receiving with the apparent gratitude of the animal the warmest thanks of her master.

sac.

"The radical cure in this case, appeared to me to be owing to the return of the hernial It was separated from a very close adhesion to the hernial pouch, by means of the fingers and the knife, and it was returned in this state of recent separation, into the abdomen, ready to attach and unite itself to any surface to which it was opposed. By its inclination to descend again, it was, although kept in the abdomen, closely applied to the abdominal ring, over the interior of which it without doubt closely adhered, and by such means completed, although in a manner I did not contemplate, the radical cure." 115.

Whether any operation of this kind is likely to be generally adopted by the profession we shall not pretend to decide, suffice it that the above was its issue in Mr. Stephens' canine friend. We fear that our limits will prevent our noticing that portion of the work which treats of mechanical obstruction of the bowels within the abdomen. We may say that the author displays much acuteness in his observations, and great boldness (shall we say temerity?) in his methodus medendi, or rather operandi. Those who wish to learn his particular views may consult the work itself, of which we can sincerely pronounce a favourable opinion, although we are far from agreeing in every respect with the author. It is for the public to decide who is right and who is wrong, and no doubt Mr. Stephens is perfectly willing to submit to its ordeal.

XII.

A SYSTEM OF HUMAN ANATOMY. TRANSLATED FROM THE FRENCH OF H. CLOQUET, M. D. By Robert Knox, M. D. F. R. S. E. &c. With Notes and a corrected Nomenclature. 1 vol. 8vo. pp. 840. Edinburgh, 1828.

ELEMENTARY Works are pouring in upon us from every quarter. In one number of our Journal we are called upon to notice two important publications on anatomy-one by Mr. Quain, a compilation-the present by Dr. Knox, a translation. These two works are very differently constructedthe former on the English model-the latter on the French. The distinctive characters of the two plans will be best understood by the following quotation from Dr. Knox's preface.

"The peculiar excellence and merit of British anatomical writers seems to be mainly connected with the originality of the views brought forward in their monographs, and even in their more voluminous systematic works: the extreme accuracy of detail, whenever the subject to be described leads to practical results; the splendid and happy physiological and pathological deductions which abound in their writings; but above all, with the discovery, if I may say so, and perfection of those descriptions of the more important surgical regions of the body, a work begun and finished solely by British anatomists and

surgeons.

"These seem to me (for I must speak with diffidence, aware of my inherent nationality) a few of the excellencies which abound in British writers; by their very presence they exclude other good qualities, which, though of a more humble and inferior cast, are yet of the utmost consequence to the anatomical student.

"The excellence here alluded to, which we in vain look for in British, and but seldom fail to meet with in Continental writers (so religiously have they copied each other from Winslow to the present day,) is that of presenting to the anatomical student a clear, methodical, and concise, yet minute description of all the parts of the human body, with brief allusions only to the uses of the parts, and with none of those alarming digressions, interlarding and disfiguring the works of English anatomists." iv.

That the plan of intermixing pathology, surgery, and physiology, with pure anatomy, is the prevailing taste of the English, there can be no doubt; and that it has its attractions and advantages it would be useless to deny. Yet, on the principle of division of labour, and utility of method, it would not be difficult to show that terse and minute anatomical description, uninterrupted by surgical or physiological digressions, is a species of knowledge which is of great utility in the tuition, and consequently in the learning of anatomy It is curious that the English have adopted the diffuse but original style of Galen, Vesalius, and some other of the older anatomical writers -while the French have servilely copied the rigid and exact style of Winslow.

"And yet with all the contempt one naturally feels for mere copyists, it must be admitted that the model followed by the Continental anatomist is, in many respects, better than our own, and that the diffuse wandering style of Galen and Vesalius, with their monstrously absurd theories and endless repetitions, will not stand a comparison with the concise and energetic manner of Winslow, his mechanical accuracy, and his brief yet perspicuous manner." iv.