HERNIA. 



7-i7 



and as complete in omental as in intestinal 

 ruptures. At a very early period of the case 

 the stomach becomes engaged, and there is 

 vomiting, at first in large quantity until the 

 contents of the stomach are evacuated ; it is 

 then less, dark -coloured, and excessively bitter; 

 and finally a substance is discharged having the 

 appearance and fetor of the feculent contents of 

 the great intestines. Considering the structure 

 and functions of the valve of the ileum, it ap- 

 pears curious how an anti-peristaltic motion 

 could be so completely established as to permit 

 of actual fcecal vomiting, and the fact (if it is a 

 fact) cannot be explained except by supposing 

 the action of all the constituent structures of 

 the intestine so deranged that the influence of 

 the valve is altogether lost. But it is more 

 than doubtful whether this material is really 

 feculent, although it is difficult from its sensible 

 qualities to consider it in any other point of 

 view; for I have frequently seen this vomiting 

 in cases where the herniae were formed of loops 

 of the lesser intestines, and therefore when the 

 contents of those beyond the iliac valve could 

 not have been thrown off; and in every case it 

 is difficult from the examination of the dis- 

 charge to determine its nature with accuracy. 

 After the stomach has been emptied of its 

 natural contents, the act of vomiting assumes a 

 very peculiar character : strictly speaking, it is 

 not vomiting or retching, nor is it hiccup, but 

 a slight convulsive effort like a gulp, which 

 brings up without much effort the quantity of 

 a single mouthful at a time. The forehead is 

 now bedewed with a cold and clammy sweat ; 

 the countenance presents a remarkable expres- 

 sion of agony and anxiety ; and the pulse is 

 small, quick, hard, and vibrating, as is the case 

 in all internal inflammations of vital parts. 



After some further time (and the period is 

 very variable) the characters of the disease 

 undergo a fearful alteration. Mortification 

 attacks the incarcerated viscus, and in most 

 instances seems to bring the result of the case 

 to a very speedy issue. The tumour now loses 

 its tense feel, and becomes soft, flabby, and 

 perhaps emphysematous : in some instances it 

 retires altogether. The belly also may become 

 soft, and in general there is a discharge per 

 anum of dark-coloured and abominably offen- 

 sive faeces. This evacuation leads the patient 

 into the encouragement of false hopes, for he 

 may have seen his surgeon endeavouring to 

 procure stools during the progress of the case, 

 and combining this circumstance with the 

 removal of the pain and the comparative ease 

 he so suddenly experiences, he fancies so favour- 

 able a change to be the harbinger of recovery. 

 But the delusion lasts not long. The pulse 

 becomes low, weak, and faltering : often it 

 intermits irregularly. The countenance is 

 sunken, and assumes an appearance that cannot 

 be described, but is known by medical prac- 

 titioners as the " facies Hippocratica." The eye 

 has a suffused and glassy look, and there is a 

 certain wildness of expression very character- 

 istic. The forehead is bedewed with a cold 

 and clammy sweat ; the extremities become 

 cold ; the sensorium is affected with the low 



muttering delirium, and death soon finishes the 

 picture. 



These symptoms have been laid down as 

 indicative of mortification having taken place, 

 probably because the protruded viscus has 

 generally been found in that state ; and from 

 habit many practitioners have on their appear- 

 ance in cases of purely idiopathic peritonitis 

 decided on the presence of gangrene, and the 

 hopelessness of recovery. Such cases are hope- 

 less, and patients have died, but not of mortifi- 

 cation, for although these symptoms are present 

 in most cases of fatal peritonitis, yet dissection 

 after death very rarely exhibits gangrene in that 

 disease, and perhaps for this reason, that the 

 functions of the abdominal viscera are too im- 

 portant to life for a patient to struggle suffici- 

 ently long with their inflammation to permit of 

 mortification being established. Whilst the 

 inflammation is very active, and the serous 

 membrane dry, or lymph only secreted on its 

 surface, then is the pain intense, and the first 

 order of symptoms developed : but when effu- 

 sion has taken place, and the vessels are relieved 

 by the pouring forth of serum or sero-purulent 

 fluid, the pain abates, and the symptoms are 

 those of extreme debility. In confirmation of 

 this remark it may be observed that, when a 

 patient dies from any sudden effusion into the 

 peritoneal cavity, whether from a ruptured 

 intestine, or gall-bladder, or bloodvessel, or 

 from any other source, the symptoms from the 

 very commencement are those of debility and 

 collapse the same sunken and anxious look, 

 the same feeble and fluttering pulse, and the 

 same kind of universal sinking of the entire 

 system. 



However, although the symptoms may be 

 very formidable, the state of the patient is not 

 altogether hopeless. Art may still accomplish 

 a great deal, and even the operations of nature 

 alone and unassisted may succeed in prolonging 

 life, although under circumstances that render 

 life scarcely desirable. When the hernia has 

 proceeded to gangrene and the patient still 

 lives, the skin of the tumour assumes a very 

 dark red and livid colour, and then becomes 

 black in spots. The cuticle separates and peels 

 off in patches, and some one or other of the 

 sphacelated parts giving way, a profuse dis- 

 charge bursts forth, of a horribly offensive 

 nature. In the same way may the surgeon's 

 interference prove serviceable. It is related by 

 Petit, that travelling once, he met in the out- 

 house of an inn an unfortunate being thrown 

 on a heap of straw in a corner to die. He im- 

 mediately recognized the smell of a gangrened 

 hernia, and proceeded to give the poor fellow 

 all the relief within his power. He made an 

 incision, allowed the feculent matter to escape, 

 cleared away the gangrenous and putrid 

 parts, and having ordered a poultice left him 

 to his fate. On his return he found him able 

 to move about and perform active service within 

 the stable, and even free from the disagreeable 

 accompaniment of an artificial anus at the 

 groin. This is a most gratifying piece of suc- 

 cessful surgery, but it is not one that is very 

 frequently realised. In order to the possibility 



