passed into a healthy abdominal cavity. But, when the finger was directed far backwards, towards the back of the abdominal cavity, I felt, with its extreme point, something tightly constricting the most distant part of the coil of intestine. It was soon clear that this tight constriction was effected by the mouth of a hernial sac, pushed back with the intestine. I therefore pulled gently on the part of the sac which had been opened, and which lay in the inguinal canal, and presently drew down the remainder of it. This formed a nearly globular swelling, between two and three inches in diameter; it was filled with small intestine, which was dark with congestion, and very tightly constricted by its mouth. The mouth of the sac, sharp-edged, hard, and unyielding, was now divided, and the intestine was without diffi culty returned into the abdomen.

[This patient recovered uninterruptedly.

In the second case the patient, an unhealthy looking man, was admitted Aug. 25th, 1853. He had had a scrotal hernia for twenty three years, but five weeks ago noticed a swelling appear in the groin, which, by means of the warm bath and an opiate, was easily reduced. The rupture for which he was admitted, did not yield so easily, and, in spite of the measures used for his relief, his condition is thus described:]

He was pallid; his face was expressive of severe suffering; and he often writhed with abdominal pain and griping about the umbilicus. He occasionally tried to vomit, and ejected small quantities of frothy mucus. In his left groin, at and just within the internal ring, one could feel a firm ill-defined swelling; but it was so painful, and so sensitive to pressure, that it was not possible to examine minutely the parts behind it, or deeper than it. In the rest of the inguinal canal, there was a slight feeling of fulness, but no other change, and one might have thought it healthy. The finger, inverting the scrotum, could be pushed into the external ring, and far along the canal, without meeting with any obstacle. The abdomen was moderately pliant, soft, and not tender on pressure. One might have felt nearly sure, that, in this case, the hernia was returned with the sac, but for the patient's account, that it was in this same state five weeks previously; that it had then returned almost spontaneously, and that for nearly six weeks, it had not been in the scrotum. But, whatever might be its state, the indications for an immediate operation were sufficient, and were followed.

On laying open the inguinal canal, there appeared in it, and extending just beyond the external ring, a collapsed portion of hernial sac, with thin, opaque walls, containing a small quantity of clear serous fluid. It was but slightly adherent to the surrounding tissues; and, when the lower border of the internal oblique and transverse muscles was freely divided, this portion of sac was found to be continuous with another part, which was distended with fluid, and stretched the

internal ring, and seemed to extend far backwards. Passing my finger on the exterior of this distended part of the sac, it seemed to go through a widened internal ring, and thence, without violence, backwards towards the sacro-iliac symphysis, or downwards to the brim of the pelvis; it did not easily pass upwards. Presently I found, that, in passing my finger on the external surface of the sac, as far backwards as possible, it seemed, at the furthest distance, to turn inwards as if towards a gradually narrowing neck and mouth of the sac. I tried to pull down what thus appeared to be the pushed-back sac; but it did not move. I therefore opened the sac at the part distended with fluid, and then pulling it down, at the same time as the parts about the internal ring and the ring itself were pulled upwards and outwards, brought the more distant portion gradually into view. This portion, which had been pushed back behind the internal ring, was about two inches in diameter, and its thickened narrow mouth tightly constricted a piece of small intestine between three and four inches long. The intestine was very dark, and its coats were thickened with congestion and with effused blood; but when the sac's mouth was divided it was returned without force.

[This patient recovered in the same favourable way. Mr. Luke's essay on cases like these, where the sac is pushed back with the intestine, render few observations necessary. Mr. Paget observes:]

In both these cases the rule was confirmed, that the erroneous mode of reduction is apt to occur in none but old herniæ; and this, though at first it may appear strange, is what might be expected: for a condition necessary to the event is, that the protruded intestine should be more tightly constricted than the mouth of the sac is, so that it may be more difficult to push the intestine through the mouth of the sac than to push the sac, or part of it, through the inguinal rings. Now, this condition can scarcely exist, unless the hernial sac have been long protruded, so that its mouth, enclosed within the narrow margin of the internal ring, may have become thickened and indurated, and less extensile than the tissues external to it.

Moreover, these two cases confirm the rule, that the reduction en masse is especially likely to happen in old oblique inguinal hernia. The rule is due to the condition just mentioned. In the majority of such herniæ, there is an annular thickening and contraction of the mouth of the sac, which appears to be due to the formation of new and tough fibrous tissue in and external to the peritoneum. The thickening forms a band or ring, one or two lines wide, which, when the mouth of the sac is exposed from without may be seen and felt as an annular constriction. It is this which constitutes the stricture in a great majority of strangulated inguinal herniæ; this which needs to be "scarified," or thinned and made extensile, when the hernia, strangulated by it, is to be returned without opening the sac. Now such an annular thickening of the mouth of the sac occurs, if not

exclusively in the oblique inguinal herniæ, yet far more commonly in them than in those of any other form; and, for the reasons above assigned, it makes them more liable than others to the accident of reduction en masse.

Neither of these cases could show exactly the manner in which the hernial sac is removed from its connexions by the force used in the reduction. One could observe no ecchymosis on the outer surface of the sac, no signs of a violent severance of its tissues from those that surrounded it. The appearance was rather as if, though the mouth of the sac might have been violently separated from the internal ring, yet the rest of the sack had been pushed back by the looser cellular tissue around it being inverted, as the tissue round a testicle is inverted when it can be pushed into the inguinal canal.

The best collective evidences for the reduction en masse appear to be-1st. The signs of strangulation continuing, or first ensuing, after the apparent reduction of a hernia; 2nd. The loss of a hernial sac, more of which, according to the history of the case, ought to be left in or beyond the inguinal canal; 3rd. A feeling of fulness at the internal ring, and, an ill-defined, firm swelling in the abdomen behind or below the ring; 4th. An amount of pain at and about the internal ring, which is quite disproportionate to that in any other part of the abdomen, as well as to the other signs of strangulated hernia; 5. The unusual drawing up of the testicle.

In these particulars, the cases I have related corroborate those already published, and confirm the rule, that, when these signs are found coincident, we should act in the belief that the reduction en masse has taken place. But the cases presented two rare and deceptive features.

1st. In each of them, the pushing back of the sac was so far incomplete, that the lower portion of it, containing fluid, remained in, and in one case projected a little beyond the inguinal canal. Feeling this portion of the sac, one might have assumed that no more had ever projected beyond the abdomen. But the case shows that we must count, among the indications of this accident, not only the complete disappearance of a hernial sac, but the marked diminution of one; that it may excite a suspicion, if we can feel, in and beyond the inguinal canal, only a much smaller hernial sac than, according to the history of the case, there should be. If, in either of these cases, the hernia had been properly reduced, its empty sack should have been felt, not only in the inguinal canal, but along the descending portion of the spermatic cord.

2ndly. In the second case, the sack had been pushed from its connexions five or six weeks before the severe strangulation ensued, and, once in the course of that time, intestine had probably been strangulated in, and returned from, the displaced sac. Such an event has not, I believe, been previously recorded; but a single occurrence of it diminishes the confidence with which we might expect that, in all

these cases, there would be the history of a very recent reduction of a hernia.

The incompleteness of a displacement of the sac, to which I just now referred, suggests a rule in operating. If, in the suspicion that a hernia has been reduced en masse, the inguinal canal be laid open, and no sac at all be found in it, the probability of an erroneous reduction is increased; but if, instead of no sac, one be found containing fluid, we might be apt to conclude that this is the whole sac, and that the intestine has been duly reduced from it. But the cases show, that the part of the sac containing and strangulating intestine may be pushed back from the internal ring, and that another part, containing fluid, may remain in the inguinal canal; they thus establish as a rule, that, in all such suspicious cases, we must not desist in the operation without being perfectly satisfied that all is right in the abdominal cavity, so far as it can be reached from the inguinal canal. In both the cases here related, after the exposure of part of the sac in the canal, the detection of its displaced but still constricting mouth was impossible, except by such an examination as would have been unjustifiable in an ordinary case. The sac's mouth was only just within reach of the forefinger, and the sensation received by the outstretched finger touching the intestine in the sac was at first deceptively like to that from intestine in the abdominal cavity.

I would add a remark on the after-treatment of strangulated hernia, as illustrated by these cases.

The abstraction of blood by nearly a hundred leeches, in the three days following the operation, in the first case, was intended against what appeared to be an active local inflammation of the peritoneum and adjacent tissues, in consequence of the violence used in the displacement of the sac and in the operation. The giving of wine on the third day after the operation, in the second case, was dictated by the fear that a peritonitis would presently ensue, against which treatment might be of little avail.

The effects of both these opposite treatments appeared to be good; and they indicated, as many other facts do, that there are at least two forms in which peritonitis ensues after operations for hernia. In one class of cases, it appears essentially the local consequence of injury; in the other, it is also, and rather, the local indication of a general blood-disease. In the one it is an active local disease, amenable to local treatment; in the other, it is only one part, one feature, of a constitutional disease of low type, which local treatment can scarcely affect for good,

We may probably compare the cases of the two classes with those of phlebitis after amputations; of which some are simple local inflammations of injured veins; others are inflammations of veins, associated with diseases of many other parts, and declaratory of diseased blood. The parallel would hold in many respects, and, among them, is this,that the peritonitis or phlebitis of local origin and nature ensues very

early after the operation, or is continuous (in the case of peritonitis) with that which preceded the operation; while the disease of constitutional origin, whether peritonitis or phlebitis, comes on later, and with an interval of two, three, or many more days, in which no signs of it may be detected. There are similar differences and correspondences in the earlier and later erysipelas after operations; the former is mainly a local disease; the latter is the localised indication of a general disease; and, as in the corresponding cases of peritonitis and phlebitis, the one is a comparatively trivial, the other a very grave, disorder.

Now, the respective indications of the earlier and the later occurence of phlebitis and erysipelas after operations, are, I believe, recognised by many; and the time that has elapsed between the operation and the access of the disease is often reckoned among the facts determining the plan of treatment. A similar rule should be held concerning operations for hernia. In general, if peritonitis ensue within twenty-four hours after the operation; or, if it existed before the operation, and continue or is increased after it, it may be assumed to be chiefly a local disease, a simple inflammation of injured parts, which may be treated by local or other bleeding, by abstinence from food and stimulus, and perfect rest; or which, if it be slight, may be left to spontaneous recovery. If, on the other hand, the peritonitis first manifests itself more than twenty-four hours after the operation, it is probably an indication of a general blood disease of some low type, for which opium and well-regulated food, or even stimulants, afford the best hope of remedy.

I need hardly say, that this difference in the time of first appearance must not be taken as alone sufficient for the diagnosis of the two forms of peritonitis, or for guidance to practice; I believe only that it may be reckoned among the most useful indications. Neither may twenty-four hours after the operation be fixed as an exact time by which, according to their advent within or beyond it, we might class all the cases of peritonitis; it is, I believe, a fair general estimate, but nothing more. Nor must the one form of the disease be regarded as exclusively a local, or the other exclusively a constitutional, malady; each is only chiefly the one or the other; and, in different cases, we may find the constitutional and the local elements of disaase prevailing in various proportions.-Med. Times and Gazette, Oct. 15, 1853, p. 392.

113.-RUPTURE TRUSS WITH SCREW ADJUSTMENTS. By DR. NEIL ARNOTT, F.R.S., &c.

[The explanation below was furnished to Dr. Quain, by Dr. Arnott, for the purpose of his lectures. Dr. Quain, for the advantage of other surgeons, takes this opportunity of making it more generally known.]

Until about a century ago, the chief remedy or means of security