742 



HERNIA. 



again can scarcely exist for any length of time 

 without producing some inflammation, and 

 thence it follows that it is rare to meet with an 

 old hernia in which adhesions have not formed 

 either between the intestine and the sac, or 

 between the convolutions of the protruded 

 viscera, circumstances that must render it im- 

 possible to replace the hernia, or supposing it 

 replaced by force, will be likely to occasion 

 incarcerations within the cavity of the abdomen 

 itself. These adhesions, as discovered either 

 during operation, or by dissection after death, 

 are of different degrees of closeness, firmness, 

 and tenacity, and have been arranged under 

 three classes, the gelatinous, the membranous, 

 and the fleshy. 



"The gelatinous adhesion, a very general 

 consequence of the adhesive inflammation 

 which attacks membranous parts placed in 

 mutual contact, is only formed by a certain 

 quantity of coagulable lymph, effused from the 

 surface of the inflamed parts, which coagulating 

 assumes sometimes the appearance of a vesi- 

 cular reddish substance stained with blood, 

 sometimes of threads or whitish membranes 

 easily separable from the parts between which 

 they are interposed and which they unite to- 

 gether, without any abrasion or laceration being 

 produced by the separation, on the surface of 

 the parts agglutinated together."* This kind 

 of adhesion being the result of recent inflam- 

 mation can rarely be met with in operations 

 performed for the relief of strangulated hernia, 

 for the condition of a viscus so engaged is that 

 in which such an effusion would be unlikely, if 

 not impossible. Its vessels are loaded and 

 congested with venous blood : there is effusion 

 of serum to a greater or less quantity, as is seen 

 in every instance of obstructed venous circu- 

 lation ; and if there is recent lymph, it must be 

 owing to the fortuitous circumstance of the 

 viscus having been inflamed immediately before 

 it became strangulated. In a vast number of 

 cases operated on, I have seen but one instance 

 of the existence of this soft adhesion, and in that 

 the hernia was not strangulated : it was a case 

 (such as is related by Pott) of inflammation 

 affecting the intestines generally, in which those 

 within the hernial sac, of course, participated. 



The membranous and fleshy adhesions are 

 the results of former attacks of inflammation, 

 and are exactly similar to those attachments so 

 frequently met with between serous surfaces in 

 other situations. When the opposed surfaces 

 lie motionless and undisturbed, their connexion 

 is firm and fleshy, and hence this kind of adhe- 

 sion is seen at the neck of the sac, between the 

 omentum and the sac, and occasionally between 

 the intestine and the testicle in congenital 

 hernia ; whilst between the convolutions of the 

 intestine itself, or between it and the sac, any 

 union that exists is more generally loose and 

 membranous. 



Besides adhesion, there are many other 

 causes that may render a hernia irreducible, 

 one of the most prominent of which is the 

 patient's neglect in leaving the hernia down, 



* Scarpa, p. 180. 



and the alterations in shape and structure that 

 thence ensue. In such case, the parts within 

 the tumour, as the mesentery and omentum, 

 have room to increase, whilst at the mouth of 

 the sac they remain constricted and of their 

 natural size, though condensed and solidified in 

 structure. This happens particularly with the 

 omentum, which becomes hard, very dense, and 

 compact, and not unfrequently resembles a 

 fibrous structure covered by a fine smooth 

 membrane, and then there is within the sac a 

 tumour actually much larger than the aperture 

 it would have to pass, and through which no 

 force could be capable of pushing it. 



It may happen that the part of the omentum 

 which is below the stricture shall remain loose 

 and expanded, and enjoy its natural structure, 

 whilst that which is lodged within the neck of 

 the sac is compressed and hardened, in which 

 case the hernia will probably prove irreducible. 

 It sometimes happens that scirrhus of the 

 intestine renders a hernia irreducible. Such a 

 malignant alteration of structure is by no means 

 frequent in the intestinal tube certainly far 

 less so than in the omentum, but the possibility 

 of the occurrence is proved by a case under rny 

 own immediate superintendence. The patient 

 had a large hernia which he had been able 

 occasionally to reduce, but which was usually 

 left down. On a sudden he was attacked with 

 symptoms of strangulation, small quick pulse, 

 tenderness of the abdomen, acute pain in the 

 tumour, constipation, general low fever and 

 fcecal vomiting. The operation was performed, 

 and the cause of the symptoms found not to 

 have been in the situation of the neck of the 

 sac, which was more than commonly open and 

 free, but in a scirrhus of one of the lesser 

 intestines.* 



The form of hernia already noticed as being 

 apparently devoid of a sac has been mentioned 

 by Pottf as one peculiarly difficult of reduc- 

 tion. " They have consisted of the coecum with 

 its appendicula and a portion of the colon. 

 Nor," continues this distinguished surgeon," will 

 the size, disposition, and irregular figure of this 

 part of the intestinal canal appear upon due 

 consideration a very improbable cause of the 

 difficulty or impossibility of reduction by the 

 hand only." 



The last circumstance to be considered as 

 rendering a rupture irreducible is the absolute 

 size of the tumour and the quantity of viscera 

 it contains. It is amazing to what extent the 

 contents of the abdomen may be protruded 

 from it, and the patient nevertheless enjoy a 

 state of health that might be called good, so far 

 as the annoyance of such a tumour could 

 warrant the expression. Every surgeon must 

 have heard of hernise in which all the loose 

 intestines were protruded, and in fact every 

 thing that could with any degree of probability 

 be supposed to have been capable of being 

 pushed from the cavity of the abdomen. I 



* The preparation of this interesting case is in 

 the Museum of the Medico-Chirurgical School, Park 

 Street, Dublin. 



t Pott, op. cit. p. 24. 



