III.KMA 



741 



under certain circumslanccs of imperfect or care- 

 li ss examination appear to In: devoid of a pro]ier 

 sae, formed by a descent of the peritoneum. 

 This occurs at the right groin, is always large, 

 and is formed by a protrusion of the caecum 

 with the appendix vermiformis and the begin- 

 iiinu of the colon. The coecum is placed in llit 

 riiilit ileo-liiinhar region, and a portion of it does 

 not possess a peritoneal covering, but lies abso- 

 lutely without the great abdominal membranous 

 sac : when therefore these parts are protruded, 

 a portion of the coecum and the beginning of 

 the colon will be found included and contained 

 in the hernia! sac, while another portion of the 

 same intestines will be necessarily without the 

 sac, and lying denuded in the cellular substance 

 which accompanies the descent of the perito- 

 neum in the hernia. If this tumour is opened 

 into by an incision carried too much towards 

 its external side, the caecum and colon will be 

 exposed lying outside of the peritoneum, and ap- 

 parently devoid of a hernial sac; but if cut 

 into precisely in the middle or a little towards 

 the inner side, under the cremasler muscle and 

 the subjacent cellular tissue, the true hernial 

 sac will be found, formed of the peritoneum. 

 Within this will be seen " the greater portion 

 of tlie coecum with the appendix vermiformis, 

 and likewise the membranous folds and bridles 

 which seem to be detached from the hernial 

 sac to be inserted into these intestines, the 

 smaller portion of which will be without the 

 sac, in the same manner as when these viscera 

 occupied the ileo-lumbar region." This form 

 of rupture I have never seen, and must there- 

 fore refer the reader to Scarpa's work, wherein 

 he will find the peculiarity most satisfactorily 

 explained. 



Hut in the arrangement of hernine, that di- 

 vision is most practically interesting which has 

 reference to the condition or state of the intes- 

 tine or other protruded viscus, and the disease 

 is then described as being reducible, or irredu- 

 cible, or strangulated. 



1 . A hernia is said to be reducible when it 

 cither retires spontaneously on the patient as- 

 suming the recumbent posture, or can be re- 

 plaeed without difficulty to the operator or 

 future inconvenience to the patient beyond that 

 resulting from the employment of measures 

 adapted to retain it within the cavity. This 

 condition supposes that the relation (particu- 

 larly as to size) between the hernia and the 

 aperture through which it had escaped has not 

 Undergone any alteration. 



2. It is irreducible when there is such a 

 change in the structure, situation, or other con- 

 dition of the protruded viscus as to render it 

 impossible to be returned, although the aper- 

 tuie through which it passed may ofler no im- 

 pediment. There is another case in which a 

 hernia has been considered irreducible, namely, 

 when it would be impolitic or unwise to attempt 

 the reduction, supposing it to be perfectly 

 practicable. 



3. A hernia is strangulated when the relation 

 as to size between the protruded viscus and the 

 apeiture thi.iu-li which it has passed is so 

 altered as not only to prevent reduction, but 



to cause such a degree of compression at 

 the ajierture as will interrupt the circulation 

 tlirniiitli the escaped visrus, and endanger its 

 vitality. This condition has been sup|K>sed to 

 exist in two different forms, strangulation by 

 inflammation and by " engouement,"* or as 

 Searpa terms them, " the acute and chronic;"t 

 but this division only has reference to the 

 severity of the symptoms and to the rapidity 

 or slowness of their progress, for although an 

 intestine may be in a state of obstruction which 

 will, if unrelieved, proceed to strangulation, yet 

 the latter state cannot be said to have arrived 

 until the return of the venous blood from it is 

 actually impeded. The protruded viscus is 

 then in a situation precisely similar to that of a 

 limb round which a cord had been tied with 

 sufficient tightness to interrupt the circulation 

 and threaten to induce mortification. 



These different conditions will be best under- 

 stood by tracing a rupture through each of them 

 in succession. 



A person may be suspected to have a reduci- 

 ble hernia when, after the application of some 

 force calculated violently to compress all the 

 viscera of the abdomen, an indolent tumour 

 appears proceeding from some of those places 

 where the walls of the abdomen are known to 

 be weakest and least resisting. And the sus- 

 picion is increased if the tumour is elastic, if 

 it sounds clearly on gentle percussion, and 

 becomes suddenly puffed up and swelled, as if 

 by air blown into it, when the patient coughs, 

 sneezes, or performs any of those actions which 

 forcibly agitate the abdominal parietes. The 

 reducible hernia becomes smaller or perhaps 

 disappears altogether when the patient lies 

 down : it appears of its full size when he stands 

 erect; if neglected, it has a constant tendency 

 to increase, which it does sometimes by de- 

 grees, slowly and almost imperceptibly, but 

 more frequently by sudden additions to its 

 bulk, which are formed by new protrusions. 

 In this form of the disease the qualities of the 

 viscus engaged within the sac, as to form, size, 

 and structure, may be considered as unchanged : 

 within the abdomen, however, the fold of 

 mesentery which supports the protruded intes- 

 tine is constantly more elongated than it natu- 

 rally should be, and likewise thicker and more 

 loaded with fat. It is also marked with dilated 

 and tortuous veins. 



Although thus displaced, the viscus is still 

 capable of performing its part in the function 

 of digestion, and as long as the contents of the 

 bowel pass fairly and uninterruptedly through 

 it, there can be little or no danger; but it is 

 not difficult to conceive how a gut so circum- 

 stanced may occasion great inconvenience. 

 The peristaltic motion must be more or less 

 impaired ; the passage of the contents may be 

 delayed, and hence will arise nausea, colicky 

 pains, crucUUions, and those other dyspeptic 

 symptoms from which even the most favoured 

 patients do not escape. These irregularities 



* Goursaud, Mem. dcl'Acad. Roy. de Chir. torn, 

 ii. p. :2. 



t Op. cit. p. 290. 



