hernia of the tunica vaginalis ;" its relation to the testicle is not invariable; and, where lying in front of that organ, might easily be mistaken for oblique hernia in its more ordinary form. In the treatment of these cases during infancy Mr. Teale prefers the employment of a pad of ivory -invested with an appropriate and easily-shifted envelope, which should be frequently changed for the sake of cleanliness. But when a hernial protrusion exists in conjunction with retention of the testicle within the inguinal canal, "a truss with a hollow pad must be employed." The existence of stricture at the mouth of the sac itself, when this form of hernia is strangulated, usually precludes, as our author admits, the practicability of operating without exposure of its interior.

The nature and treatment of "direct inguinal hernia" occupies the next chapter. Though presenting nothing original, to justify a lengthened quotation, we consider the directions given by our author for conducting the operation in this form of rupture when strangulated judicious,

and as constituting so fair an illustration of his practice and style, that we transcribe the passage which contains them.

"As the surgeon is unable to pronounce with certainty that the hernia is direct, it is his duty, whenever he operates for a strangulated inguinal hernia supposed to be direct, to proceed under the constant apprehension that the hernia may possibly be oblique. If the local and general symptoms are such as to warrant his attempting to relieve the stricture without opening the sac, a small incision should be made over the upper part of the tumour, from above downwards, so as to expose the external ring and the upper part of the fascia of the cord; an opening of small extent being next made into the latter, a flat director (Key's) should be passed upwards under the external ring, and, if it exert any material pressure on the tumour, a few of its fibres should be divided by the bistoury. If, however, it be found that the stricture is not formed by the external ring, and if the cremaster be found spread over the tumour, it should be turned aside by the point of the director, or, if necessary, divided by the knife, in order to ascertain if the next envelope present the smooth, firm, resisting character of an aponeurotic membrane; and, should this be the case, the membranous covering should be cautiously opened, and a flat director insinuated beneath it towards the abdomen, when any of its fibres which may appear to exert a constricting influence may be divided by the blade of the knife directed upwards. If, on the contrary, after opening the fascia of the cord, and turning aside the fibres of the cremaster, a loose filamentous tissue, more or less loaded with fat, present itself, the operator may presume that this is the subserous tissue pushed before the sac through a rent in the aponeurotic structures. It then becomes necessary to search for the upper edge of this aperture, and, after insinuating the director beneath it, to divide it upwards, and thereby remove the stricture. If, however, it is now found that these parts, external to the sac, have not been the seat of stricture, the operation must be completed by enlarging, if necessary, the external incision, and dividing the subserous tissue and the sac.

"Lastly, the director must be introduced within the stricture from the interior of the sac, and the constricting band divided; the operator always bearing in mind that he must direct his incision in this, as in all other forms of inguinal hernia, upwards from the middle of the mouth of the sac; and no presumptuous deviation from this rule, from a confident feeling in his own powers of diagnosis, can be justified under any circumstances." (p. 295-6.)

As in the preceding chapters, that which follows on "femoral hernia" is introduced with some notice of the anatomy of the region and parts concerned. In his description of the femoral sheath, and the walls of the

femoral ring, we cannot help recognizing what we consider factitious anatomy rather than the simple reality. In the first place we should question, were we so disposed, the continuity of the femoral sheath and the fascia transversalis; but this may pass, for if we entered on this subject at all, it would be requisite clearly to define what is meant by the sheath of a vessel, which we hold to be anything but identical with a tendinous or fascial bed in which it may chance to lie. But, as regards the crural ring itself, the anatomy, as far as we have ever been able to make it out, is very simple; this space being bounded by the iliac fascia, Poupart's ligament, the vein, and Gimbernat's ligament; and closed by the cribriform fascia, extending from the last-named boundary to the femoral vein. As to the existence of any septum, properly so called, between the ring and vein in the normal condition, we know of none, nor can we conceive what purpose it could answer. It is true that the cribriform fascia (of Sir A. Cooper) may be and is so prolonged by continued and gradual pressure, as to form an investment of femoral hernia; and it is thus that the sac is separated from the vein. The condensed structure which occupies the saphenic opening is altogether independent of the femoral sheath, by which we mean the close cellular investment of the vessels, as well as distinct from the fascia transversalis, which can hardly be said, under any circumstances, to extend beyond Poupart's ligament. However, we are aware that we are on debatable ground; and our only desire is to enter our protest against the tendency which certainly exists with some writers of complicating practical anatomy by describing things as they think they ought to be, rather than as they really are. But this is not a charge we can bring against our author; although we think his anatomy of the femoral ring and sheath might a little puzzle a beginner. Again, we may remark, that though it is doubtless true, that the adhesion of the reflected border of the saphenic opening to the cellular sheath of the vessels is a barrier to the descent of a hernia within the fascial envelope, still we do not think that sufficient importance is attached to the ingress and egress of the bloodvessels and lymphatics at this part, by which the superficial and deep parts are, as it were, closely pinned together, and the protrusion is thus forced to take an upward direction, pushing before it the cribriform and saphenic fasciæ. A remark of our author's which follows we quite concur in, viz. that the tumour in crural hernia "usually projects over the semilunar edge of the femoral aponeurosis below, and over Poupart's ligament above, encroaching in the latter direction on the site of inguinal hernia. But," he adds, "this encroachment is not produced by the entire tumour turning upwards, as has been frequently represented, but is simply the result of the general enlargement of the body of the sac in comparison with the aperture through which it has escaped." Mr. Teale informs us that he has operated on a femoral rupture in a male, which was as large as two fists; this size, however, is very rare; as are other instances in which the relation of the hernial sac to the femoral vessels is described as different from that which we have indicated.

The complications of femoral hernia noticed by our author, and which it is necessary for the surgeon to be acquainted with and prepared for, are the coexistence of inguinal rupture, the presence of serous cysts, and enlarged lymphatic glands. He mentions an instance which recently came

under his notice, of the rare complication of two inguinal and two femoral hernia in the same subject.

The seat of stricture in femoral hernial has been the subject of considerable dispute and difference of opinion; and we do not doubt that the disputants have been all more or less in the right, though we are free to confess that our own observation leads us to place it in by far the largest proportion of cases in the sharp border of Poupart's ligament which overhangs the ring. Mr. Teale ascribes it to the femoral sheath in most instances, and quotes Sir A. Cooper and Mr. Key as confirming this view.. It is certainly a very delicate point to decide, inasmuch as the adhesion of the so-called sheath to the posterior aspect of Poupart's ligament, (the "intermixture of aponeurotic fibres," to use our author's own expression), entirely destroys the individuality of these structures at this point; and though it may be true that these aponeurotic fibres below Poupart's ligament aid in strangulating a protruded portion of gut, yet we very much question whether their division alone would suffice to relieve the stricture. In short, we do not recollect to have witnessed a case in which the stricture was relieved (when its seat was the fibrous ring in front, and to the inner side of the neck of the sac,) without a more or less decided division of the posterior border of Poupart's ligament.

When reviewing M. Malgaigne's work we noticed his test for diagnosing crural as distinguished from inguinal hernia, we need not therefore now repeat it; the directions are given at length in the volume now before us. Nor is it necessary to notice the distinguishing characteristics of varicose veins and psoas abscess, which can scarcely be mistaken for hernia where ordinary caution is employed in conducting the examination of the patient. The "statistics and causes of femoral hernia we may likewise pass by; but on the treatment of this form of rupture we have a few words to say before we leave it.

The employment of trusses in crural hernia is a palliative measure, which conduces very importantly to the patient's comfort and safety; but they effect little else, on account of the nature of the bounding textures of the ring, which tends to render its abnormal size permanent. As Mr. Teale remarks, it is important that the pad for these trusses should not be of large size, as it is then so readily displaced by the action of the adductor and flexor muscles of the thigh; and it is also important that it should not rest on the pubes. The following are his directions for the construction of a common single truss for reducible crural hernia.

"It should have the pad of a triangular form, narrow transversely, and somewhat elongated from above downwards; its base corresponding with the edge of Poupart's ligament. The pad should be of size sufficient to close the saphenous opening, but should only extend to a very limited distance beyond the borders of this aperture. Its convexity should constitute a rather prominent ridge, directed from above downwards, situated a little towards the pubic side of the pad, commencing about a finger's breadth below its upper edge, and extending downwards to the apex, towards which part it should gradually diminish. A pad thus constructed gently closes the external aperture, namely, the saphenous opening; and its most intense pressure is directed to the pubic side of the vein." (p. 327.)

Surgeons should not think themselves, as many do, above this purely mechanical part of their art; for how could a mere mechanist construct

an apparatus, which it requires an accurate knowledge of anatomy to render available? Where a surgeon can add to his professional acquirements a practical familiarity with mechanics, he possesses a considerable advantage over another who is without this knowledge, not only in the use of his hands, but in the construction of his appliances to boot.

In the treatment of irreducible femoral hernia, our author strongly recommends a hollow pad, consisting of a "flat ring of metal supporting a concave metallic plate inclosed in a bag or cap of wash-leather. The metallic ring should be adapted to the size and form of the particular hernia, so that it may rest upon the parts immediately surrounding the tumour, without exerting any direct pressure upon it; whilst the leathern cap, spread over the opening of the ring, should possess such a degree of concavity as to enable it to support and to exert a gentle pressure upon the hernia." This form of truss Mr. Teale has not found obnoxious to the objections which Sir A. Cooper had to their employment in this form of irreducible hernia.

The operative course to be pursued when strangulation exists is judicious; and we are willing to acquiesce in our author's recommendation, that the stricture should be divided, where it can be done satisfactorily and safely, without opening the sac; and we quite believe that the surest rule for the division of the stricture is to direct the edge of the bistoury upwards and forwards.

In the chapter on "umbilical hernia," there is not much to attract our attention. A truss invented by Mr. Eagland, of Leeds, and which was highly commended by Mr. Hey, is that which our author prefers in ordinary cases of umbilical rupture. It is figured in the work before us, and consists of a convex cork pad, and a horseshoe spring attached by a hinge to either side. When there is a very lax and pendulous state of abdomen, Mr. Teale advises that the pad should be attached to "a broad plate of steel of very moderate concavity;" or if necessary, an ivory compress retained by adhesive plaster may be employed. The frequent fatality of this form of hernia, when strangulated and subjected to operation, certainly justifies the remark that the sac should not be opened, if the stricture can possibly be relieved without this step.

The remaining chapters of the work treat successively of "ventral, obturator, ischiatic, perineal, vaginal, pudendal, and diaphragmatic herniæ." Mr. Teale is enabled to add but little from his own personal experience to our information regarding these less common forms of hernia. He narrates one fatal case, which occurred in his own practice, of ventral hernia. In protrusions at the anterior wall of the vagina, a truss, “consisting of a compress supported by a spiral spring, so as to press upon the external labia," is spoken of in the highest terms, as applicable where an internal pessary cannot be borne; this instrument is also manufactured by Mr. Eagland, of Leeds.

We must here bring our analysis to a close, hoping that our readers have seen sufficient to satisfy them that our commendation has not been misplaced, but fearing likewise the fulfilment of our own hinted prediction, that the task we are concluding is one which, from its monotony, it is not most easy to render agreeable to the reader. Yet, although we cannot award to Mr. Teale the merit of originality, to which indeed he does not

profess to lay any claim, we consider that he is entitled to our warmest thanks for having given to the profession so valuable a text-book in this important and intricate branch of surgery.

The subject is handled with that practical familiarity which cannot fail to engender confidence, and at once to instruct and interest the reader. The style is simple, terse, and pure, without bordering on dogmatism on the one hand, or falling away into vagueness or indecision on the other. Altogether, we may repeat, that we have rarely had it in our power to recommend a work with such unmixed confidence and satisfaction to our readers and this we do most cordially to all classes, but especially to students and junior practitioners, who will find it an invaluable and unfailing guide in their early operations and maiden difficulties.

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ART. XVIII.

The Young Stethoscopist; or, the Student's Aid to Auscultation. By H. J. BOWDITCH, M.D.-Boston, (U. S.) 1846. 12mo, pp. 248. THIS is, in one respect, a very original book on auscultation. It includes a description of that method of diagnosis in its applications to the lower animals; it is illustrated by a variety of woodcuts representing square pieces of India-rubber (p. 39), numerous stethoscopes, and a horse (p. 224); while its sections are headed with pictorial letters, after the manner of our facetious friend Punch. All this may not be without its utility, as the book is expressly designed for junior auscultators. Our notice of its contents will be limited to comments on a few points which have struck us in turning over the pages.

Dr. Bowditch appropriates the phraseology and observations of writers on this side the Atlantic, with very imposing coolness; at this we do not feel any surprise: but how does Dr. Bowditch venture to lay hands on the property of his neighbours of Philadelphia (Dr Gerhard is located there, we believe,) without some fear of exposure? He gives the exact explanation long since tendered by the Philadelphian physician, of the natural state of prolonged expiration at the apex of the right lung, without the slightest reference to its author's name. We ourselves doubt extremely whether Dr. Gerhard's be the true explanation of the fact; but, true or false, the idea of the phenomenon being dependent on the greater width of the right than the left bronchus, should have been conceded to Dr. Gerhard.*

Dr. Bowditch has twice heard the "pulmonary crumpling sound" (of Fournet) in "apparently early stages of tubercular disease. It was connected with no other physical sign, and occurred at the end of inspiration. Both patients had had hemoptysis; both apparently regained their health." In certain cases of bronchitis, both acute and chronic, says Dr. Bowditch, "you may get no physical signs." This is true most perfectly, if understood to apply to the ruder class of signs, as rhonchi and great change in the sound of percussion; it is untrue, if referred to trifling alteration in the respiratory murmur.

"Twice" Dr. Bowditch "has observed a very curious phenomenon in the second stage of pneumonia of the posterior portions of a lung; viz.

* Or, if not to him, to Fournet, who taught the same doctrine, and illustrated it by a figure. XLIII.-XXII.

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