SURGERY. 
by tlie sudden removal of the support from 
the abdominal viscera. 
HERNIA 
Is a tumour formed by the passage 
of any of the abdominal viscera from the 
cavity in vphich they are naturally con- 
tained, into a preternatural bag, formed by 
the protrusion of the peritoneum. The pro- 
truded portion of peritoneum is called the 
hernial sac. This peritoneal sac is covered 
by another investment of various degrees of 
thickness, consisting probably, in great part, 
of the surrounding cellular substance, con- 
densed into a membrane-like appearance, 
by the pressure of the hernia ; in the same 
way as tumours acquire their investing cyst. 
In the inguinal hernia this external coat of 
the sac possesses some tendinous fibres in 
its structure, derived from the aponeurosis 
of the external oblique, where it forms the 
ring. The cremaster muscle is also expanded 
on its surface ; it consists usually of several 
layers, the division of which, in the operation, 
often leads the surgeon to suppose that he 
has opened the hernial sac. Scrotal rup- 
tures often descend to various distances on 
the thigh, sometimes indeed even to the 
knee ; yet the whole inner surface of the 
bag, in which all the loose viscera of the ab- 
domen may be contained, is lined by a con- 
tinuation of peritoneum ; indeed the hernial 
sac, taken altogether, is generally thicker 
and stronger in proportion to the size of the 
tumour, and to the duration of the com- 
plaint. The exterior covering is every 
where closely connected by cellular sub- 
stance to the proper peritoneal sac. Hence 
the latter part is not returned into the ab- 
domen, when the contents of the swelling 
are replaced, but remains behind ready to 
receive any future protrusion. When the 
parts have descended tlirough the abdomi- 
nal ring, the case is called a bubonocele, or 
inguinal hernia ; if they are in contact with 
the testis it is termed congenital. The 
crural or femoral is that which takes place 
under Poupart’s ligament; and the ex- 
omphalos, or umbilical rupture, occurs at the 
navel. The names of enterocele, epiplocele, 
and entero epiplocele, are applied'according 
as the swelling contains intestine, omentum, 
or both together. These are by far the 
most frequent forms of the complaint ; yet 
there are several others, as ventral hernia, 
which takes place between tjie fibres of the 
abdominal muscles ; hernia of the foramen 
ovale, ischiatic notch, &c. While tlie visc^jra 
descend and return freely, tlie complaint is 
said to be in a reducible state; ,but when 
from increase of bulk, preternsftural adhe- 
sions, or other causes, they are incapable of 
being returned, it is termed irreducible. An 
incapacity of reduction, arising from stric- 
ture in the opening, through which the vis- 
cera have descended, brings it into the in- 
carcerated or strangulated state. The causes 
of hernia are of two kinds ; the occasional, 
or exciting, which consist of all those, by 
which the pressure of the abdominal Viscera 
against the sides of the cavity is increased, 
as in straining, and all forcible actions of 
the respiratory muscles ; and the predispo- 
sing, which favour the occurrence of rup- 
ture in particular individuals, as an unusually 
large state of the openings, or lax condi- 
tion of the margins of those apertures. 
A reducible hernia is an indolent tumour, 
smaller in the recumbent position, larger in 
the erect posture ; diminishing, or entirely 
disappearing by means of pressure; large 
and tense after a meal, or when the patient 
is troubled with wind, soft and small in the 
morning, before he has taken any food ; at- 
tended occasionally with a rumbling sensa- 
tion, particularly on its return, and rendered 
tense when, the patient coughs, so as to 
communicate an impulse to the hand of the 
examiner. Various visceral derangements,, 
as colic, constipation, and vomiting, are oc- 
casionally attendant. Uniformity and elas- 
ticity of the tumour, together w’ith the 
rumbling noise, and the feeling of impulse 
on coughing, show that the case is an 
enterocele ; but if the swelling be com- 
pressible, fiabby, and uneven, free from 
tension on coughing, and slow in returning, 
the contents are omentmn. 
A reducible hernia, although not imme- 
diately dangerous, leads to many unpleasant 
consequences, from its constant increase in 
size, and the visceral derangements that 
ensue from this cause. It is also constantly 
liable to strangulation. 
In a strangulated hernia, the protruded 
parts become inflamed, and this affection is 
propagated over the rest of the surface of 
the abdomen. Hence pain of the part, 
and tension of the belly, are early symp- 
toms. An entire suppression of the fecal 
discharge is also a very leading character. 
Nausea and vomiting ensue ; all the con- 
tents of tlie stomach, and afterwards those 
of the intestines, down to the stricture, 
being rejected. The whole system is de- 
ranged ; there is great anxiety and rest- 
lessness, with a small and hard pulse, and 
cold extremities. At length hiccough su- 
pervenes, the pulse is hardly sensible, the 
respiration weak, and the whole body is 
