After some further time (and the period is very variable) the characters of the disease undergo a fearful alteration. Alortification 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 dischargeper anum of dark-coloured and abominably offen sive faces. 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 lie 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 Ilippocratica:' 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 vesselsare 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.
llowever, 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. Ile im mediately recognized the smell of a gangrened hernia, and proceeded to give the poor fellow all the relief within his power. Ile 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 of an artificial anus being formed, the patient and the hernia must be placed under circum stances so very peculiar that it will be easily perceived how unlikely it is that they should be united and combined in one individual.
1. Although the protruded viscus has become sphacelated, the inflammation within the ab domen must not have reached such a height as to preclude the possibility of recovery.
2. Adhesions must be established between the bowel and the peritoneum either at or im mediately above the neck of the sac, so that when the stricture is free and the enormous alvine accumulation allowed to escape, it will be impossible for the gut to withdraw itself within the cavity or be removed from the external aperture.
And in order that the annoyance of the arti ficial anus should be subsequently removed, it is necessary that the intestine and the perito neum to which it is adherent should retire into the abdomen, and that the angle between the two intestinal tubes should be diminished or removed.