HERNIA. 



745 



tion of such a case is reckoned from the first 

 occurrence of symptoms, which at that period 

 are only those of indigestion, it will be an ex- 

 ample of a very chronic case of strangulated 

 hernia ; but these two stages of the disease 

 ought to be distinguished, for the treatment 

 that would be judicious in the one might be 

 injurious or destructive in the other. The in- 

 carceration of a hernia does not, moreover, ne- 

 cessarily involve its eventual strangulation, and 

 this constitutes a vast difficulty in the case, for 

 on the one hand few surgeons will advise an 

 operation until there is an obvious and decided 

 necessity for it, and on the other it is quite 

 possible in a case of this description that the 

 symptoms shall never be urgent, and yet the 

 intestine be found in a state of actual sphace 

 lus. I have seen a patient operated on in 

 whom the hernia had been down and the 

 bowels constipated for eighteen days. The 

 intestine was completely mortified. 



That strangulation which is most rapidly 

 formed is the most severe in its symptoms and 

 the most dangerous in its consequences, but 

 between these extremes there is every possible 

 degree of intensity. A hernia has been gan- 

 grened in eight hours after protrusion. Mr. 

 Pott frequently mentions a single day as caus- 

 ing a most important difference in the case, 

 and 1 have found an intestine sphacelated en 

 the day following the first occurrence of the dis- 

 ease; however, in general the case is not so 

 quickly decided, although every moment of its 

 duration is pregnant with danger. The change 

 that is effected in the strangulated viscus next 

 demands attention. Its altered condition has 

 been always spoken of under the name of in- 

 flammation,* not from want of a perfect and 

 accurate knowledge of its pathology, but pro- 

 bably from the term appearing convenient and 

 being hastily adopted by one writer from ano- 

 ther. Yet as it is not inflammation, the name 

 is incorrect, and perhaps it has been injurious 

 in leading practitioners to attempt a mitigation 

 of the inflammation in the tumour, instead of 

 the more obvious indication, a diminution of 

 its size. The volume of a strangulated intes- 

 tine is always increased. In small hernias 

 (which in this respect can be more accurately 

 examined) the intestine, on the sac being divi- 

 ded, starts up and swells out as if relieved from 

 a compressive force. It always contains air, 

 and if cut into, a small portion of dark-coloured 

 serum will generally escape. Its colour, which 

 is manifestly occasioned by an accumulation of 

 venous blood, is at first of a reddish tint of 

 purple, soon however changing to a coffee 



: * n T ne inflammation that takes place in stran- 

 gulated hernia is different from almost every other 

 species : in most cases it is produced by an unusual 

 quantity of blood sent by the arteries of the part, 

 which become enlarged ; but still the blood returns 

 freely to the heart, and the colour of the inflamed 

 part is that of arterial blood ; whilst in hernia the 

 inflammation is caused by a stop being put to the 

 return of the blood through the veins, which pro- 

 duces a great accumulation of this fluid, and a 

 change ot its colour from the arterial to the venous 

 hue. Cooper on Hernia, p. 20. 



brown, and there is always more or less of 

 serum within the sac, as in every other case of 

 venous congestion. If unrelieved, dark and 

 fibrous spots appear which are truly specks of 

 mortification ; they very soon separate and 

 allow a discharge into the sac of a quantity of 

 putrid faeces and horribly fetid gas. This 

 done, the intestine either remains collapsed 

 within the sac, or retires spontaneously into the 

 abdomen. 



In the meantime the parts covering the 

 hernia become inflamed; in the first instance 

 probably from sympathy with the deeper struc- 

 tures, afterwards obviously as an effort of nature 

 to get rid of the putrid and sphacelated matter 

 underneath. In the early stages the local symp- 

 toms are seldom very severe: the tumour is 

 scarcely painful, and will permit reiterated at- 

 tempts at the reduction of the hernia, and en- 

 dure considerable pressure, whilst the abdomen 

 may not be touched without intense suffering. 

 In a little time, however, it becomes tense and 

 tender to the touch, red, cedematous, and pitting 

 under the finger, which leaves a white impres- 

 sion for a moment after it has been withdrawn. 

 In fact, it is erysipelatous inflammation attack- 

 ing the coverings of the hernia, and its approach 

 is often accelerated by handling the tumour or 

 by repeated injudicious attempts to reduce it. 

 This (if the patient lives sufficiently long) 

 always terminates by the formationof oneor more 

 sloughs, on the separation of which the putrid 

 coverings are thrown off, and the contents of 

 the bowels being evacuated, the patient's life 

 may be saved, but with the inconvenience and 

 danger of an artificial anus at the groin. It is 

 seldom that the efforts of nature are thus ca- 

 pable of procuring relief, the contents of the 

 rupture being generally sphacelated, and incu- 

 rable mischief effected within the abdomen 

 long before its external coverings shew any dis- 

 position to burst spontaneously. I think the 

 condition of the sac has some influence on this 

 external inflammation. In all cases it under- 

 goes a less injurious alteration of structure than 

 the intestine contained within it, and is often 

 found comparatively sound while the latter is 

 in a state approaching to sphacelus. The supe- 

 riority of its vascular organization, its containing 

 a greater quantity of blood, and moreover the 

 volume of air always contained within the 

 bowel, will explain this pathological difference; 

 but the sac itself sometimes suffers from con- 

 gestion to a greater or less extent, and this, of 

 course, in proportion to the degree of con- 

 striction fixed upon its neck. An old hernial 

 sac, the neck of which is thickened and ac- 

 customed to its new position, and which is 

 itself probably one of the chief causes of the 

 stricture, will be less likely to suffer from an 

 interrupted circulation than a recent protrusion 

 just forced out through a narrow undilated 

 ring. It is in this latter case that the external 

 structures ought to be the soonest engaged, and 

 it has been in recent and acute cases of hernia 

 that I have seen the earliest examples of super- 

 ficial inflammation. 



3. Such, during the progress of a hernia, is 

 the condition of the parts more locally engaged; 



