746 



HERNIA. 



but a far more serious because a more fatal 

 process is going forward within the abdomen. 

 It must be recollected that a gangrene of the 

 intestine when out of the abdominal cavity is 

 not necessarily fatal ; that the gut may die and 

 putrefy, and be thrown off by the results of 

 external inflammation and sloughing, and yet 

 the patient live for many years witli an artificial 

 anus, or even have the natural passage per unum 

 restored again. Numberless cases of artificial 

 anus have thus occurred, not one of which 

 could have been saved if the sloughing of the 

 intestine was inevitably mortal. But soon 

 after the strangulation is effected, either from 

 the pressure on the viscus, which may be sup- 

 posed to have a material influence, or from the 

 mechanical obstruction to the passage of the 

 fseces, inflammation is established within the 

 cavity, commencing probably at the strictured 

 spot, and spreading thence with great rapidity. 

 The part of the peritoneum most engaged is 

 that which covers the line of intestine inter- 

 posed between the stricture and the stomach ; 

 the least, that which invests the walls of the 

 cavity. This inflammation may be in part 

 salutary, for it occasionally causes an adhesion 

 of the intestine at the neighbourhood of the 

 ring so firm that it cannot be removed there- 

 from, and thus provides for the occurrence of 

 an artificial anus subsequently without the 

 danger of any internal effusion ; but unless the 

 stricture is relieved at this time, and a check 

 thus given to the progress of the disease, the 

 intestines become matted with lymph, effusions 

 are poured out of a similar nature to those that 

 occur in other forms of peritonitis, and the 

 patient dies not of the gangrene of the pro- 

 truded intestine, but of the peritoneal inflam- 

 mation within. 



On opening the body of a person who has 

 thus died, the intestines above the stricture are 

 found inflamed, of a red or pink colour, greatly 

 distended with flatus and perhaps with faecal 

 matters ; below the stricture they are inflamed 

 also, but remarkably diminished in size. There 

 is always an effusion of lymph to a greater or 

 less extent glueing the convolutions of the 

 bowels together, and there is often on the sur- 

 face of the peritoneum not covered with lymph, 

 a dark appearance as if blood was ecchymosed 

 beneath it. Effusions are also constantly met 

 with, sometimes apparently of pure pus, 

 diffused, particularly throughout the spaces 

 formed by the apposition of the convoluted 

 intestines, sometimes more abundant, and con- 

 sisting of serum mixed with lymph in loose 

 and floating flakes; and occasionally a more 

 gelatinous substance is observed very much re- 

 sembling the jelly-like material that surrounds 

 frog-spawn in stagnant ponds. I have never 

 met the existence of gangrene within the ab- 

 domen in any case of deatli from strangulated 

 hernia. 



The line of intestine, then, within the ab- 

 domen, and the loop within the sac, are diffe- 

 rently circumstanced. Above the stricture 

 there is active inflammation exactly such as 

 might occur idiopathicallv, presenting the same 

 morbid appearances, and accompanied by a 



similar train of symptoms : below, there is a 

 state of venous congestion in which the vessels 

 endeavour to relieve themselves by pouring out 

 a serous effusion, and in which gangrene super- 

 venes with a rapidity proportioned to the tight- 

 ness of the constriction. Between these, and 

 immediately under the stricture, it is white, 

 pale, and bloodless all round for the space of 

 two or three lines, and appears to be diminished 

 in size more than it really is on account of the 

 great enlargement immediately above and below. 

 The condition of this strictured ring of intestine 

 is of the utmost importance in the progress of 

 the case, for it is not uncommon for it to ulce- 

 rate or to slough under the influence of the 

 continued pressure. I have seen an operation 

 admirably performed, and the intestine returned 

 under apparently favourable circumstances, 

 yet the patient sink and die in the course of a 

 few hours : a small hole existed in the con- 

 stricted spot, through which faecal matter had 

 escaped and become diffused within the cavity. 

 In another instance, from the anxiety of an 

 operator to inspect the condition of this spot 

 previous to the return of a hernia, the intestine 

 in the act of being drawn out tore almost as 

 easily as a wetted rag. 



It will not be difficult to connect the symp- 

 toms of this disease with the morbid alterations 

 just described. When a hernia is about to 

 become strangulated, the earliest symptom is 

 in general pain, at first referred to the seat of 

 the stricture, but soon becoming diffused over 

 the abdomen, when the chief suffering is often 

 seated in the region of the navel. The belly 

 then becomes hard and tense, at first rather 

 contracted, but subsequently swollen and tym- 

 panitic : it is exquisitely tender to the touch, 

 cannot endure the slightest pressure, and in 

 some cases even the contact of the bed-clothes 

 is intolerable. The patient lies in bed with 

 his legs drawn up, and if possible his shoulders 

 bent forward on the trunk ; he cannot without 

 excessive torture endeavour to move himself in 

 any direction, and a moment in the sitting pos- 

 ture is not to be endured. Of course when 

 the whole canal of the intestine is constricted, 

 there must be constipation of the bowels ; yet 

 cases have been mentioned in which, though 

 all the other symptoms of strangulated hernia 

 were present, the discharges from the bowels 

 have not ceased, a circumstance that has been 

 explained by the supposition that only a por- 

 tion of the circumference of the intestine was 

 engaged. I believe, however, that most of 

 these cases were delusive, and that when the 

 alvine discharges have continued to a very late 

 period, the case was one of incarceration in 

 which peritoneal inflammation may not be 

 established for a long time or perhaps at all ; 

 or else the practitioner was deceived by some 

 of those discharges from the line of intestine 

 below the stricture which are so frequently 

 brought away by the administration of enemata. 

 The explanation of the symptom is too mecha- 

 nical, particularly when it is recollected that 

 idiopathic inflammation of the peritoneum will 

 generally (although not always) produce the 

 same effect, and that it is as regular, as constant, 



