372 A TREATISE ON INGUINAL HERNLE. 
Practical observations show us, that old herriiae become strangulated 
from engorgement, and not from stricture of the neck of the sac at the ring: 
these can be considered but as secondary causes. And tliis explains why 
the symptoms of strangulation are in all cases essentially alike, varying only 
in the tardiness of their progress and succession. 
It is to be observed here, however, that many subjects of her¬ 
nia not only escape strangulation, but continue to do their work 
with a large hernial scrotum, and, to all appearances, without the 
slightest inconvenience, barring that which may arise from the 
weight, and dependance of the tumour. It is a knowledge of this 
fact which leads us to warn the practitioner against surgical in¬ 
terference with these cases, unless symptoms of strangulation, or 
such as our author has here detailed, should render it absolutely 
necessary: under any circumstances, we apprehend, they are not 
cases ‘‘ devoutly to be wished for.’^ 
It is not always easy to distinguish scrotal enterocele from other swellings 
of the genitals, and particularly when the hernia is complicated with sarco- 
cele or varicocele, or thickening of the chord, or a combination of these. 
The tumour of an enterocele does not preserve a general uniformity; it is 
commonly most bulky next the abdomen, increasing from below up\vard; 
at times it is greatly diminished, and even occasionally shrinks into the 
natural volume of the scrotum. It yields to pressure, and returns to its form 
after being compressed: raise the tumour with the hand, and it sensibly 
diminishes in volume, in consequence of part of its contents withdrawing 
into the abdomen: a guggling noise sometimes attends this retraction. 
Should the exploration of the inguinal canal be deemed advisable, the 
opening will be found more or less dilated and encumbered, an unerring 
test of the presence of the disease. 
In such a predicament as this, we shall recall to mind, with pe¬ 
culiar advantage, the expansion of the swelling under the influence 
of coughing, a test which we hesitate not to affirm would, in 
almost all cases, supersede the troublesome business of exploring 
the inguinal canal. 
^ In almost all chronic hernicC we meet with serous effusion, either into the 
cavity of the tunica vaginalis, or into the cellular membrane uniting the 
hernial coverings. Morbid thickening of these tunics is a much more rare 
occurrence, and one of w hich M. Girard has seen few examples. 
IV.—CONGENITAL ENTEROCELE. 
This last species, the most frequent but the least dangerous, is an attend¬ 
ant on birth, increasing up to the third or sixth month; afterwards diminish¬ 
ing, and ultimately vanishing. Should it continue, without loss of volume, 
beyond a year or eighteen months, it may be regarded as, and is, in fact, a 
chronic hernia. Should the tumour, however, instead of augmenting or 
remaining unaltered, diminish at intervals, and continue to do so more per¬ 
ceptibly, it will at length withdraw itself altogether, though it return again; 
until, the relapses growing less marked, and the intervals longer, the gut no 
more enten^ the ring. 
