prehended the very worst consequences. To me, however, it appeared so decidedly a palpitation from nervous irritability, that I really fear I treated it more lightly than was prudent, and certainly had not the credit of being a true prophet, although the result has fully confirmed my opinion, for he is now in good health, and free from disease, real or imaginary. Liverpool, Oct. 9, 1832.

SOME OBSERVATIONS

ON THE VALUE OF THE DIFFERENT SIGNS

WHICH DISTINGUISH THE

SAC IN STRANGULATED HERNIA;

WITH SOME

PRACTICAL REMARKS ON THE OPERATION,

AND

CASES IN ILLUSTRATION.

BY J. H. JAMES,

Surgeon to the Devon and Exeter Hospital.

So extensive and various have been the writings on the subject of hernia, that it is scarcely credible that any point belonging to it could still demand illustration; nor should I have believed it to be so, if I had not found that, in more respects than one, our information is not so complete and precise as it ought to be: and thinking it possible that others, as well as myself, may have felt the inconvenience of the deficiency, I shall endeavour to remedy it in some

measure.

The point to which I now particularly allude, is the mode of ascertaining, during the operation of hernia, whether it be sac, or whether it be intestine which presents; the enquiry, however, will involve some other matters.

It is well known that the dangers incident to this operation, occur chiefly at two periods, one in open

ing the sac, the other in dividing the stricture, the following observations will, perhaps, shew that it is pardonable in me to express a doubt whether the former point has received that complete and deliberate elucidation it demands, and may warrant me in suggesting some improvements in this branch of pathology.

It will be evident, from the writings of all the older surgeons, that the greatest dread was entertained on this head, and their manipulations justly condemned by M. Louis,* arose from their apprehensions. They had the additional cause of alarm, that they were not completely masters of the anatomy, natural or morbid, of the parts, and this, as it commonly does, proved a source of dread and mistake.

vantages de

anatomy of the

Great and successful labour has since been bestowed, in ascertaining the number of the investments, their nature, and their precise relations to the protrusion. This inquiry chiefly answers one Practical ad- practical purpose, that of informing us rived from the what progress has been made in the opeinvestments. ration, and what further division will be required, before the contents are laid bare; and if in every case we could exactly ascertain this point, we should require no further guide, because their number being known, we should, at once, determine what part actually presented itself, from the consideration of those we had already divided; but this, unfortunately, is often rendered very unford a complete certain, by the number of layers into which the external investments may sometimes

Does not af

and precise diagnosis.

* Mem de l'academie. T. 11. p. 452, et seq.

be split, most deceitfully, on the one hand, while, on the other, they sometimes adhere to each other, or to the sac; while the sac itself may be either very thick, or of extreme tenuity. To shew that I have not overstated these difficulties, I shall not rely on the cases I could produce myself, (although some of them may be mentioned) but shall quote some authorities on the subject, which will hardly be questioned.

1st.-In bu

First, with regard to the investments in bubonocele, Scarpa says, p. 62,* "On bonocele. making an incision into a scrotal hernia, of large size and long standing, we met with, in the first place, the aponeurotic web of the fascia lata,† and the sheath of the cremaster muscle, unusually dense, rigid, and somewhat coriaceous; then the cellular substance lying between the sheath of the cremaster muscle and the hernial sac, presents itself, so firm and indurated, that, at first sight, it appears to be a dense and compact capsule, formed of Uncertainty many layers lying one over the other; of the number lastly, under an indeterminate number of these layers, of hard cellular substance, the true hernial sac appears, the density of which, in spite of its excessive bulk and long standing of the hernia, does not at all, or very little, exceed the natural pellucidity and thinness of the perito- And thinness

neum."

of the layers.

of the sac.

I could produce other authorities for the multiplication of laminæ, but it will not be required. I may also refer to some of the cases I have related in the

* Translation by Wishart.

+ Fascia Superficialis.

sequel, especially the 1st and 2nd. With respect to the division of this sac, when exposed, Sir A. Cooper Caution re- says, "The surgeon must proceed to open it with the utmost caution ;"* expressions, we may be sure, he would not have employed without good reason.†

quired.

But it is not so much in large scrotal herniæ, whether old or recent, that the difficulty chiefly occurs; it is in small inguinal, and more especially in femoral hernia that we find it; and I shall now proceed to state succinctly in what it consists in the latter species, as far as the investments are concerned.

2nd. In fe

In the first place, beneath the superficial fascia, which itself varies much in thickness, we encounter the fascia propria, which does not merely moral hernia. cover the sac, but surrounds it completely,§ and is precisely of its form, so much so, that it has been denominated by Sir C. Bell, the false be confounded sac, and not unfrequently is mistaken for with true sac. the true sac. I

Fascia propria, liable to

Secondly, beneath this, and externally to the sac, there is often a considerable quantity of cellular and

* Lectures, p. 41, v. 3rd; and Sharpe says, "This is a part of the operation which, perhaps, demands the most delicacy in operating of any other."-Crit. Inq. p. 28.

+ And Mr. Hey. "This caution is particularly necessary when the hernial sac is to be opened, as the prolapsed intestine is sometimes in close contact with the internal surface of the sac, without any intervening fluid." p. 141.

Sir A Cooper, 10th, 11th, and 12th cases.

§ Sir A. Cooper on fem. hern. fol. part 2, p. 6. Sir C. Bell's Surg. Obs. vol. 1st, 211.

|| Sir C. Bell, 211–13.

¶ Sir A Cooper, ib. p. 16. Hey, p. 136. Scarpa, (so as in some persons to resemble omentum) 251. Lawrence, p. 352.