be reducible, when the protruded bowel or viscus readily returns into
the abdomen on the application of pressure to the swelling, or on the
patient assuming the recumbent posture. When recent, the swelling may
not be made to disappear without considerable difficulty; but, after
the disease has become of long duration, the aperture through which
the protrusion has taken place dilates and is relaxed, and admits of
the ready passage of the hernial contents: such tumours are usually
of considerable size. But reducible herniæ should not be permitted to
enlarge, since their protrusion can be prevented by simple and safe
means; after reduction, a properly fitted bandage, termed a Truss,
is applied over the aperture and canal, and by the compression thus
made the opening is rendered impervious to the abdominal viscera. In
inguinal hernia, the pad of the truss must make equable compression
over the whole of the canal; in the other species, the aperture is less
extensive, and the pressure more direct. Perseverance in the use of
a well-adapted truss is highly necessary in children from the first,
so that a chance may be afforded of permanent cure by contraction of
the opening and development of the surrounding parts. In young persons
the canal is short, and almost direct, and from its becoming oblique
and elongated during growth, prevention of protrusion may be effected.
Descent must never be allowed during such attempts at cure. But in
adults such a fortunate result can scarcely be expected; the truss
must be constantly worn during the day—in bed it may be disused—and
the patient must rest satisfied with thereby escaping those dangers to
which protrusion of the hernia would render him always liable. Great
care should be taken to ascertain in the morning, before the truss is
applied, that no protrusion exists. If the opening be not much dilated,
it may contract even in adults when protrusion is sedulously prevented.
The patient will also require to avoid the causes of hernia. If he is
subject to cough, or labours under bad urinary disease, by which the
abdominal muscles are called frequently and fully into action, there
is no chance of a cure; nothing but the continued use of a truss will
afford safety.
Hernia is rendered irreducible, 1. By the formation of adhesions
between the sac and the included parts. 2. By induration of the
protruded omentum, and by accumulation of fat in it, or in the
appendiculæ of protruded large intestine. 3. By contraction of the
abdominal cavity from long-continued displacement of a large portion of
its contents. 4. By the nature and connexions of the protruded part,
as in hernia of the sigmoid flexure, or of the caput cœcum coli. 5.
By firm compression of the abdomen. 6. By the tightness of the opening
giving rise to engorgement of the protruded parts. 7. By accumulation
of feces, solid or fluid, in the protruded portion of bowel. With
care, some of these causes may be got over, and the tumour reduced.
In irreducible hernia the use of a bag truss is indispensable to
prevent increase of the protrusion. In irreducible femoral hernia of
small size, a hollow pad with a weak spring is used with advantage,
to give support to the contained parts, prevent farther protrusion,
and guard the tumour against external violence. The patient must avoid
violent exertion, keep his bowels open, and be careful of his diet; he
is always in danger, and should know it. Many have lost their lives
from blows otherwise not dangerous; and even straining at stool is
sufficient to force additional portions of viscera into the neck of
the sac, and thereby induce most serious distress. Ruptures often come
down during an attack of bowel complaint, or after a dose of purgative
medicine.
The term _incarceration_ of hernia is employed to indicate a slight
degree of _strangulation_, when the hernial contents are confined from
any cause, and when the circulation in the protruded bowel and the
course of the feculent matter are nevertheless uninterrupted. By many
it is applied indiscriminately with strangulation.
_Strangulation_ arises, not from any change in the neck of the sac or
in the tendinous aperture, but from increase of volume in the protruded
parts, caused by accumulation of the solid, fluid, or gaseous contents
of the bowel, followed by interruption to its circulation; or the
interruption to the flow of blood may precede the distension. The
circulation is more readily retarded or arrested in the veins than in
the arteries, and consequently the engorgement of the bowel is at first
caused by venous turgescence; but when the flow in the arteries is at
all impeded, the infiltration and exudation become more rapid, and the
part quickly perishes—sphacelates. The symptoms which accompany and
indicate strangulation are of a very imposing nature, and cannot be
neglected; and it is fortunate that such is the case, for no disease
is fraught with greater or more immediate danger to the patient, or
requires more the early interference of a skilful and expert surgeon.
The tumour becomes tense and painful, and the integument is sometimes
red and shining; the pain is much increased by pressure, and extends
over the abdomen, but continues most severe near the neck of the
swelling; sickness and inclination to vomit quickly follow; the patient
feels languid; his countenance soon assumes a contracted anxious
appearance; the circulation is hurried; the pulse beats wiry and hard,
though at first it may have been full. If relief is not afforded,
all the symptoms are speedily aggravated; vomiting comes on, and is
frequent; no discharge can be procured from the upper bowels, though
the lower may be, and often are, evacuated by injections or by natural
efforts: if the upper bowels evacuate downwards, the strangulation
cannot be of the whole calibre of the gut, but only of a part. Pain
and heat in the tumour and belly increase; and the former becomes very
tender, and tense as a drum. The circulation is more hurried, and
restlessness and intolerable anxiety supervene. The patient becomes
worse and worse every hour; feculent matter in large quantity is
vomited or gulped up with great distress, and is commixed with bile,
with vitiated mucous secretion from the stomach and bowels, and with
whatever may have been recently swallowed; in fact, the peristaltic
action of the alimentary canal above the strangulated part is inverted,
and all the contents are ejected. Troublesome hiccough comes on, and
this symptom is by many considered as a sure sign of gangrene having
taken place; but it is often present when the bowels are quite free
from tenderness or tendency to gangrene. The extremities grow coldish;
the pulse is unequal and fluttering, and with difficulty counted at
the ankles. The countenance sinks, and assumes a leaden hue; the pain
abates suddenly; the eyes are glassy; the tumour becomes flaccid,
and is often livid and emphysematous. Now, the bowel may recede, and
feculent evacuation take place, with some relief; but the patient,
after lying some time insensible, expires. All this may occur, either
within a few days after the occurrence of strangulation, or not till
after the expiration of many days. The rapidity of the symptoms and the
danger are influenced by the size of the tumour and the condition of
its neck, and by the nature of its contents. In small recent herniæ,
the advance from bad to worse is usually very rapid, the aperture
through which protrusion has taken place being small, and producing a
great degree of constriction when distension and engorgement occur.
When the neck of the tumour is large, and completely occupies the
aperture previously to the strangulation, the progress of the symptoms
is also rapid, for a similar reason; but if the hernia be large and
of long standing, and if the protruded parts are not bulky at the
point of protrusion, the constriction is in general not very severe,
and the distressing consequences advance more slowly. The symptoms
are not so violent in epiplocele as in enterocele. In many instances
of the former, the intestinal discharges are never obstructed, though
great irritation and inflammation may be induced by the strangulation.
There is also less danger in entero-epiplocele than in enterocele,
compression of the bowel being in the former instance diminished by the
intervening omentum.
It is scarcely necessary to observe, that, when the train of symptoms
just detailed commences in any case, the surgeon must immediately and
anxiously inquire as to the existence of external hernia, for often
the disease is concealed, particularly by females: all parts where
protrusion is likely to occur must be examined attentively. At the same
time, the surgeon must bear in mind that pain of the abdomen, with
symptoms resembling those of strangulation—in fact, that enteritis,
with obstruction, may exist along with hernia, but independent of
it. A person with hernia is as liable as any other, if not more so,
to inflammatory attacks in the abdomen from a variety of causes. The
portion of bowel in the tumour may participate or not in the general
abdominal affection; if unaffected, it may be reduced; it is neither
painful nor tense. Again, in large ruptures, inflammation of the
contents may take place without strangulation, and without affection
of the parts within the abdomen. All circumstances bearing on the case
must be well considered by the surgeon, before making up his mind as to
the nature of the affection.
Returning the contents of the hernia into the abdomen is the only
effectual means of counteracting the direful effects of strangulation;
and the propriety of an early recourse to this measure must be quite
apparent. It is indispensable, and no delay is warrantable. The
means for accomplishing it must be varied, according to the state of
the parts, the duration of strangulation, and the general symptoms.
The most simple method, and that which should first be attempted in
ordinary cases, is the _taxis_; that is, reduction by pressure with
the hand. In this, the position of the patient is of importance; it
should be such as effects relaxation of the tendinous structures
through which the hernia has protruded, and through which it is to be
returned. With this view he is placed on his back, with the shoulders
and pelvis elevated, and in crural hernia the thigh is bent on the
trunk, and turned towards the opposite side; thus the aperture is
relaxed along with the fasciæ which compose it. Long ago, the positions
into which the patients were forced for the cure of hernia were
various, and generally awkward; they all tended towards more or less
complete inversion of the erect posture, and thus it was supposed that
the abdominal bowels dragged on those protruded, and thereby assisted
reduction. But the viscera are equally pressed on in every position of
the body; it is not they, but the external parts, that are affected by
change of posture. During the attempts at reduction, the patient should
be exhorted not to strain or resist, but to relax his muscles; and it
will be well to engage him in conversation, that he may not have an
opportunity of keeping his lungs distended, and thereby acting forcibly
on the abdomen. At first the pressure should be general, applied either
with one hand or with both, according to the size of the tumour, so as
to diminish the contents. If air be heard gurgling at the neck of the
swelling, the chance of success may be considered good, for a return
of part of the bowel’s contents is thereby indicated. Then a gentle
kneading should be made at the neck with the fingers of one hand, while
with the other general pressure is kept up. The impression made is at
first slight and gradual; but, when a portion of the bowel returns, the
rest of it slips up suddenly. The return of omentum is always slow, and
the last part requires as much manipulation as the first. The direction
of the pressure must be varied according to the case. In inguinal and
ventro-inguinal hernia, it is made in the direction of the neck of the
sac; in the former upwards and outwards, in the latter upwards and
backwards; and previously the body of the tumour should be brought
into the same line with its neck. In crural hernia the pressure must
first be made towards the centre of the thigh, so as to bring the whole
tumour into the same direction with its neck, and then upwards. In
umbilical, the pressure is straight backwards. Small herniæ, and those
of recent origin, are with difficulty reduced; their neck is narrow,
and the passage proportionately small; the crural are usually of this
description. In all herniæ, after strangulation has existed for some
time, and adhesions formed, particularly at the neck, reduction is
almost impossible.
The taxis is to be neither attempted nor persevered in after the
hernia has become tender and inflamed. No good can be done by it, and
the patient’s chance of recovery by operation is much diminished.
Even when no pain is felt in such circumstances, any degree of force
must be prejudicial. Mortification of the bowels is often hastened in
consequence of the taxis being unskilfully employed by ill-informed
persons, who are often determined, at all risks, and at all stages
of the affection, to accomplish speedy reduction of the viscera. The
surgeon will take care to inform himself of all particulars—as to the
duration of strangulation, the previous state of the tumour, if it was
all, or only in part reducible, as to its size, &c.—before proceeding
in any way. Great mischief is likely to accrue from the tumour being
handled, perhaps roughly, by many people. If the taxis is gone about,
however, in proper time, and in the right way, it ought almost always
to prove successful. It is very desirable indeed that this should
be the case, seeing that all the bad symptoms in ninety-nine out of
a hundred cases instantly subside; whereas, after the reduction by
incision, there is always great risk from the opening of the peritoneal
sac alone.
Certain means may assist the taxis, but they should not be long
continued or often repeated. Venesection can be employed only in
strong plethoric patients, in the very first stage of strangulation,
and before the patient is exhausted by the distressing symptoms. It
is had recourse to in order to induce syncope, or an approach to it;
during which general relaxation takes place, and reduction may be
attempted with advantage. With that view the patient is placed erect,
and a large orifice made in the vein of one or both arms, so that a
moderate quantity of blood suddenly abstracted may have a powerful
effect on the system. In several cases I have found this practice
beneficial, but am inclined to say that, in general, it will not be
followed with success. In a favourable case, one attempt of this kind
may be made, but not repeated. In many states of the constitution, and
in the latter stages of the disease, bad consequences must follow the
practice. But in regard to it or any other remedy, it would be folly
to lay down positive general rules; what may prove useful in one or
two instances may answer very badly in the majority of cases that come
under treatment. Local bloodletting can have no effect in diminishing
the size of strangulated parts; though in inflammation of the contents
of the tumour, without strangulation, no more powerful means can be
employed.
Purgatives have been recommended with the view of extricating the bowel
by increased peristaltic motion; but the symptoms will, to a certainty,
be aggravated by their use. Purgative enemata can do little good: if in
small quantity, they empty only the rectum; if large, they may reach
the strangulated part, but will scarcely have the effect of extricating
it.
Emetics, in full or nauseating doses, have been supposed to be
indicated in this affection as well as in ileus; but there is in
general enough of sickness and vomiting without them, and it is often
difficult enough to allay the vomiting even after removal of the
obstruction.
The warm bath is greatly trusted in by some, and in many cases
it proves a valuable and useful auxiliary to the taxis. It acts
beneficially by inducing general relaxation, or even syncope; during
which, whilst all resistance of the compressing powers upon the
contents is suspended, pressure on the tumour can be employed to good
advantage. By steady perseverance, whilst the patient is in the bath, a
great majority of strangulated herniæ may be reduced. But neither the
general nor the local application of heat, or any other known means,
save the edge of the knife, can relax tendinous apertures farther
than can be effected by attention to position. Irrecoverable and most
precious time may be wasted in preparing the bath; and for this reason
such means should never be resorted to, unless they can be commanded at
the shortest notice.
Fomentation can do no good. The apertures can be neither relaxed
by heat, nor contracted by astringent applications. By the local
application of heat, the size of the parts composing the hernia will be
augmented, the flatus being rarified, and the effusion and engorgement
encouraged.
The cold bath, and the dashing of cold water on the surface, near the
seat of the disease, have been tried in some rare cases with most
marked success; but this is a practice not generally to be relied
on. It can act only by producing sudden and powerful contraction of
the coverings, and uniform pressure thereby on the contents. It is,
perhaps, only applicable to scrotal hernia. Cold has been applied to
the tumour, and even ice, so as to produce frost-bite, but little
faith can be placed in such; the practice becomes dangerous after
inflammation has existed for some time, the application diminishing the
weakened powers of the parts, and accelerating gangrene.
Opium has been given by the mouth, and tobacco by the lower extremity
of the alimentary canal; the former may sometimes prove advantageous,
but the latter had better be dispensed with. The tobacco is thrown up
either as an enema, or in the form of vapour; but the former method is
generally preferred. A drachm of the leaves is infused in a pound of
water for ten minutes, and one-half of the liquid injected; if this
prove insufficient to prostrate the patient, the rest is administered
after the lapse of a short interval. But many people have thus been
poisoned, and the indiscriminate employment of the supposed remedy
cannot be too strongly reprobated; its effects are most severe and
unmanageable; the state of collapse is most complete and alarming, and
it is often difficult, if not impossible, to bring the patient out of
it—to procure reaction. In some cases reduction may be accomplished
during the state of extreme debility which follows its use, but I
have often seen it fail, and have witnessed the operation afterwards
performed on the patients, who were at the time without pulsation,
and from whom little blood flowed after the incisions; they never,
of course, rallied, and sunk rapidly. Indeed the patient is always
in a very unfavourable state for operation after the exhibition of
the tobacco enema, though certainly in a very favourable state for
reduction being attempted. The strong objection to the medicine I
conceive to be its being so extremely unmanageable; it is impossible
to say whether the depression of the vital powers that must ensue will
be just sufficient to induce that relaxation and debility necessary or
favourable to reduction, or whether it will proceed uncontrollable to
such a degree as to extinguish life. In general it produces intolerable
nausea and depression, universal relaxation of the muscles, coldness
of the surface, with clammy exudation, vomiting, violent retching,
vertigo, and perhaps insensibility. Were I so unfortunate as to be the
subject of strangulated hernia, I should certainly have no tobacco
used. After unsuccessful trial of the taxis, I might submit to be bled
ad deliquium, and have a surgeon to attempt reduction during syncope;
if somewhat more advanced in life, I should prefer the warm bath; if
taxis then failed, I should certainly be operated on in a very few
minutes afterwards. If the surgeon, after mature consideration, make up
his mind as to the course of practice he would wish pursued in his own
case, he will be fully alive to the necessity of impressing the utility
of it on his patients, and have little difficulty in persuading them to
submit to his proposals. No time should be dissipated in administering
purges or clysters, or in cold or warm applications.
If the tumour is not very tender, make one good trial of the taxis,
not long continued; if a warm bath can be readily commanded, place the
patient in it, and employ the taxis when he begins to feel faint. If
foiled, and if the patient can bear depletion well, the strangulation
being recent, try a full bleeding to syncope; it may save depletion
afterwards, and at all events the patient will be none the worse for
it. Having failed, as may probably be the case, operate without delay.
The operation, as regards the immediate consequences, is neither
formidable nor dangerous of itself; the delaying of it is attended with
the most serious and irretrievable mischief. It ought to be performed
within a very few hours after the occurrence of strangulation, and,
in most instances, without putting off time with the means considered
auxiliary to the taxis. Under urgent circumstances, it may be necessary
to operate within a quarter of an hour after seeing the patient, as
I have often done. In ordinary cases, time must be taken to converse
with the patient and his friends, to convince them that all those
means likely to assist reduction, and render an operation unnecessary,
have been tried. The surgeon must not appear to be in a hurry, though
he puts off no time unnecessarily; otherwise his motives may be
misconstrued.
The necessity for operating early is greater in small than in large
herniæ, in crural than in inguinal. The groin and neighbouring parts
are to be shaved, and the patient placed in the recumbent posture,
with the shoulders slightly elevated. The mode of operation must be
varied according to the nature of the tumour, its size, and other
circumstances.