750 



HERNIA. 



If it is so large or otherwise so circumstanced 

 as entirely to impede communication, and if 

 in this condition it is neglected, the discharge 

 must take place at the groin, and the disease is 

 permanent. Such, I believe, is the history of 

 most of those unhappy beings who have borne 

 about them for years this loathsome and dis- 

 gusting affliction, until relieved by a death that 

 could not have proved unwelcome. In a vast 

 number of cases the projection is not so great, 

 and although it may impede and delay, it does 

 not altogether prevent the passage of faeces 

 from one portion of the tube to the other: 

 then as the external wound contracts, the neck 

 of the sac forms into a membranous funnel or 

 canal of communication, and the faeces begin 

 to pass. The wound then heals, in some in- 

 stances leaving a small fistulous opening 

 through which a limpid, straw-coloured, but 

 fetid fluid constantly distils, whilst in others a 

 perfect and complete cicatrix is formed. But 

 we must recollect what happens in this seem- 

 ingly perfect cure before we can fully appreci- 

 ate the entire nature of the case, and the degree 

 of danger that always overhangs it. It is 

 evident that the viscus must (at least at first) 

 be firmly fixed at the situation of the cicatrix ; 

 that it no longer enjoys any freedom of motion, 

 and that it forms an angle more or less acute at 

 the place of adhesion. It is also probable that 

 the diameters of the two portions of intestine do 

 not correspond. Hence the process of diges- 

 tion is impaired, the patient must study every 

 article of food he consumes, and the slightest 

 indiscretion is followed by colicky pains, flatu- 

 lence, and tormina of the bowels; often there is 

 nausea, vomiting, loss of appetite, and a drag- 

 ging sensation at the stomach, this latter symp- 

 tom being explained by the omentum having 

 formed a part of the protrusion, and become ad- 

 herent at the new-formed cicatrix. It often 

 happens that the scar gives way, and a faecal 

 discharge takes place again, the groin thus 

 alternately healing up and bursting out anew. 

 This is more likely to occur in cases where the 

 very small fistulous canal has remained, and 

 therefore many surgeons have regarded this 

 event as more fortunate than where the cica- 

 trization has been complete ; for the course of 

 the fistula serves as a guide to direct the burst- 

 ing of the accumulation externally, whereas if, 

 as sometimes happens, the intestine should give 

 way internally, its contents are then poured 

 out into the peritoneal cavity, and the result 

 must be inevitably fatal. 



The most curious circumstance connected 

 with the healing of an artificial anus is, that 

 the position of the united intestines and the 

 intervening infundibulum or funnel behind the 

 cicatrix is not permanent. "It is," says Scarpa,* 

 " a certain fact confirmed by a very great num- 

 ber of observations, that after the separation of 

 the gangrene the two sound segments of intes- 

 tine retire gradually beyond the ring towards 

 the cavity of the abdomen, notwithstanding the 

 adhesion which they have contracted with the neck 

 of the sac, whether this is caused by the tonic 



* Scarpa, op. citat. p. 313. 



and retractile action of the intestine itself and 

 of the mesentery, or rather by the puckering of 

 the cellular substance, which unites the hernial 

 sac to the abdominal parietes within the ring. 

 And this phenomenon is likewise constant and 

 evident even in herniae not gangrenous, but 

 merely complicated with fleshy adhesions to 

 the neck of the sac, and therefore irreducible. 

 In these herniae, the immediate cause of stran- 

 gulation being removed, the intestine, together 

 with the hernial sac, gradually rises up towards 

 the ring, and at last is concealed behind it." 

 The same fact has been observed by Dupuy- 

 tren,* who attributed it to the continued action 

 of the mesentery on the intestine. Many indi- 

 viduals who had been cured of artificial anus 

 without operation returned to the Hotel Dieu 

 at very remote periods, and died of diseases 

 having no relation to the original complaint. 

 The parts were curiously and carefully examined, 

 and the intestine, instead of being fixed to the 

 walls of the belly, was found free and floating 

 within the cavity. There could be no doubt 

 of the identity of the individuals, and moreover 

 a fibrous cord was seen extended from the point 

 of the wall of the abdomen which corresponded 

 with the former artificial anus, to the intestine. 

 This cord, some lines in diameter and some 

 inches in length, thicker at its extremities than 

 in the middle, covered by peritoneum, and 

 formed entirely by a cellular and fibrous tissue 

 without any cavity, was evidently produced 

 by the progressive elongation of the cellular 

 membrane that had united the intestine to the 

 wall of the abdomen ; and the cause which 

 had occasioned this elongation was nothing 

 else than the traction exercised by the mesentery 

 on the intestine in the different motions of the 

 body during life. 



Having now endeavoured to describe gene- 

 rally the circumstances or conditions under 

 which protrusions of the abdominal viscera may 

 exist, I proceed to consider the peculiarities 

 that arise from situation, premising that it is 

 not my intention to enter very minutely into 

 the descriptive anatomy of those several situa- 

 tions in their normal or healthy states, but only 

 in reference to and in connexion with the ex- 

 istence of the disease under consideration. 



Inguinal hernia. When a viscus is pro- 

 truded through one or both of the apertures 

 termed rings, situated at the anterior and infe- 

 rior part of the abdomen, near the fold of the 

 groin, but above Poupart's ligament, the hernia 

 is termed inguinal. It may exist, therefore, in 

 three different conditions. 1. Where the in- 

 testine has been pushed through the internal 

 ring only, and is lodged in the inguinal canal : 

 it then appears as a small, round, firm, and 

 moderately elastic tumour. 2. Where it has 

 passed through the internal ring, through the 

 inguinal canal, through the external ring, and 

 dropping down into the scrotum of the male or 

 the labium pudendi of the female, appears as a 

 larger and more yielding tumour, of a pyrami- 

 dal shape, the apex of the pyramid being di- 

 rected towards the anterior superior spinous 



* Le9ons Orales, torn. ii. p. 207. 



