3. Such, during the progress of a hernia, is the condition of the parts more locally engaged; but a far more serious because a more fatal process is going forward within the abdomen. It must be recollected that a gangrene of the intestine when out of the abdominal cavity is not necessarily fatal ; that the gut may die and putrefy, and be thrown off by the results of external inflammation and sloughing, and yet the patient live for many years with an artificial anus, or even have the natural passage per anurn restored again. Numberless cases of artificial anus have thus occurred, not one of which could have been saved if the sloughing of the intestine was inevitably mortal. But soon after the strangulation is effected, either from the pressure on the viscus, which may be sup posed to have a material influence, or from the mechanical obstruction to the passage of the faces, inflammation is established within the cavity, commencing probably at the strictured spot, and spreading thence with great rapidity. The part of the peritoneum most engaged is that which covers the line of intestine inter posed between the stricture and the stomach ; the least, that which invests the walls of the cavity. This -inflammation may be in part salutary, for it occasionally causes an adhesion of the intestine at the neighbourhood of the ring so firm that it cannot be removed there from, and thus provides for the occurrence of an artificial anus subsequently without the danger of any internal effusion ; but unless the stricture is relieved at this time, and a check thus given to the progress of the disease, the intestines become matted with lymph, effusions are poured out of a similar nature to those that occur in other forms of peritonitis, and the patient dies—not of the gangrene of the pro truded intestine, but of the peritoneal inflam mation within.
On opening the body of a person who has thus died, the intestines above the stricture are found inflamed, of a red or pink colour, greatly distended with flatus and perhaps with faecal matters ; below the stricture they are inflamed also, but remarkably diminished in size. There is always an effusion of lymph to a greater or less extent glueing the convolutions of the bowels together, and there is often on the sur face of the peritoneum not covered with lymph, a dark appearance as if blood was ecchymosed beneath it. Effusions are also constantly met with, sometimes apparently of pure pus, diffused, particularly throughout the spaces formed by the apposition of the convoluted intestines, sometimes more abundant, and con sisting of serum mixed with lymph in loose and floating flakes ; and occasionally a more gelatinous substance is observed very much re sembling the jelly-like material that surrounds frog-spawn in stagnant ponds. I have never met the existence of gangrene within the ab domen in any case of death from strangulated hernia.
The line of intestine, then, within the ab domen, and the loop within the sac, are diffe rently circumstanced. Above the stricture there is active inflammation exactly such as might occur idiopathically, presenting the same morbid appearances, and accompanied by a similar train of symptoms : below, there is a state of venous congestion in which the vessels endeavour to relieve themselves by pouring out a serous effusion, and in which gangrene super venes with a rapidity proportioned to the tight ness of the constriction. Between these, and immediately under the stricture, it is white, pale, and bloodless all round for the space of two or three lines, and appears to be diminished in size more than it really is on account of the great enlargement immediately above and below. The condition of this strictured ring of intestine is of the utmost importance in the progress of the case, for it is not uncommon for it to ulce rate or to slough under the influence of the continued pressure. I have seen an operation admirably performed, and the intestine returned under apparently favourable circumstances, yet the patient sink and die in the course of a few hours : a small hole existed in the con stricted spot, through which faecal matter had escaped and become diffused within the cavity.
In another instance, from the anxiety of an operator to inspect the condition of this spot previous to the return of a hernia, the intestine in the act of being drawn out tore almost as easily as a wetted rag.
It will not be difficult to connect the symp toms of this disease with the morbid alterations just described. When a hernia is about to become strangulated, the earliest symptom is in general pain, at first referred to the seat of the stricture, but soon becoming diffused over the abdomen, when the chief suffering is often seated in the region of the navel. The belly then becomes hard and tense, at first rather contracted, but subsequently swollen and tym panitic : it is exquisitely tender to the touch, cannot endure the slightest pressure, and in some cases even the contact of the bed-clothes is intolerable. The patient lies in bed with his legs drawn up, and if possible his shoulders bent forward on the trunk ; he cannot without excessive torture endeavour to move himself in any direction, and a moment in the sitting pos ture is not to be endured. Of course when the whole canal of the intestine is constricted, there must be constipation of the bowels ; yet cases have been mentioned in which, though all the other symptoms of strangulated hernia were present, the discharges from the bowels have not ceased,—a circumstance that has been explained by the supposition that only a por tion of the circumference of the intestine was engaged. I believe, however, that most of these cases were delusive, and that when the alvine discharges have continued to a very late period, the case was one of incarceration in which peritoneal inflammation may not be established for a long time or perhaps at all ; or else the practitioner was deceived by some of those discharges from the line of intestine below the stricture which are so frequently brought away by the administration of enemata. The explanation of the symptom is too mecha nical, particularly when it is recollected that idiopathic inflammation of the peritoneum will generally (although not always) produce the same effect, and that it is as regular, as constant, and as complete in omental as in intestinal ruptures. At a very early period of the ease 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 focal 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 hernia 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.