is placed recumbent on a table, or, in private practice, on the side of
a bed, his shoulders supported by pillows, and his feet resting upon
a stool. An incision is commenced about an inch above the external
abdominal ring, and continued to the bottom of the tumour. This
latter part of the procedure, however, is applicable only to small
and moderately-sized herniæ; in large tumours the wound is not made
so low, for in them the bowels may be irreducible, from the quantity
protruded, and the contracted state of the abdominal cavity; in such
cases the incision should be only to such an extent as is sufficient to
enable the operator to reach the stricture. The first cut is carried
through the skin and fatty matter, not deeper. The layers are then
divided successively, with the hand unsupported; and this is done only
at the middle and projecting part of the swelling. It is unnecessary
to prolong the incision of the layers along the whole extent of the
wound in the integuments, at this stage of the proceedings. In the
direct hernia, which is of rare occurrence, there is but one proper
layer,—that furnished by the superficial abdominal fascia: not
unfrequently there is an imperfect additional envelope, furnished by
fibres from the edge of the external ring; sometimes the tumour does
not escape through the external ring, and is then of course covered
by the tendon of the external oblique; of this I have seen but one
instance, and that in a female; but in a common inguinal hernia there
are three or four, and these are thickened more or less according to
the size and duration of the tumour. The division of these layers must
necessarily be conducted with great care and caution. At length the
sac is exposed. This is opened by pinching up a portion betwixt the
nails of the thumb and forefinger, or with dissecting forceps, and then
cutting with the blade of the knife laid horizontally. On wounding the
sac, there is usually evacuated a small quantity of brownish serous
fluid. The probe-pointed bistoury is then taken up, and insinuated
into the opening; and by this instrument, guided on the forefinger of
the left hand, the sac and its coverings are divided up to near the
ring, and down to near the bottom of the tumour. The hernial contents
are thus exposed. These are unravelled, and examined attentively; if
only brownish-red, from accumulation of the venous blood, of unbroken
surface and unadherent, they are fit to be reduced. The stricture is
felt for with the forefinger of the left hand, and into it either the
point of the finger or the nail is gently insinuated. The protruded
parts, if voluminous, are held down by an assistant; and along the
forepart of the finger is passed a probe-pointed, narrow, and slightly
curved knife. In carrying this upwards, the blade is placed flat on the
finger, and its point, and no more, is passed through the contracted
part; its edge is then turned forwards, its back resting on the finger;
and by raising the handle gently, a slight incision is made into
the more resisting fibres, in the direction of the mesial line. The
instrument is withdrawn with the same caution as in its introduction.
The finger now enters easily, and by raising it gently and repeatedly
the parts are dilated. It is then passed upwards to the site of the
internal ring: and if this be found narrow and contracted, the edge of
the knife to be directed against it in a similar way, and dilatation to
a sufficient extent effected. Now reduction is to be commenced, and in
doing so the same precautions are to be observed as in the employment
of the taxis. The hernial sac ought in the first place to be fixed by
the fingers of the assistant placed in the bottom of it, so that it
may be prevented from sliding up along with the contents. A neglect of
this rule is often observed to lead to much embarrassment. The parts
seem to have passed back into the general cavity; but on withdrawing
the pressure they fall down again from the canal, along with the sac
which had slipped up so far with them. In general, the omentum, if any,
is put back first, and then the bowel; but this must depend on the
relative quantity of the parts, and other circumstances. With the right
hand the bowel is to be compressed as uniformly as possible; and, if
at all obstinate, its reduction may perhaps be accelerated by pulling
down a small portion at the neck, so as to facilitate the return of the
fecal contents. By gentle pressure with the forefingers one portion
is put back after another: it is wrong to attempt sudden and entire
reduction; it should be gradual and successive. In many cases, from
adhesion, or from the bulk and nature of the hernia, the parts, though
sound, cannot or ought not to be reduced; a portion may be got back,
but part requires to remain. This can often be ascertained beforehand
by properly conducted and previous inquiry into the history of the
case, as to the duration of the disease, and the period at which the
whole tumour could be made to disappear. In such cases, the stricture
should always be freely relieved. When the bowel is mortified, and its
contents effused into the sac, care is to be taken not to detach or
disturb the adhesions at the neck, and the bowel should be opened so as
to allow of free discharge. When the bowel or omentum are comparatively
sound, though irreducible, the surgeon must rest contented with
relieving the stricture; then cover the parts with the integuments,
and promote union of the wound. If it be considered necessary to
remove condensed and tuberculated omentum, it is cut off, and separate
ligatures of fine thread are applied to every bleeding vessel on the
cut surface; the whole mass is not to be included in one noose, as was
formerly the practice.
[Illustration]
In the operation for femoral hernia, the position and preliminaries
are the same as for inguinal. A longitudinal incision is made from
above the margin of Poupart’s ligament to a little below the middle and
most prominent part of the tumour. This is crossed by another at its
lower extremity, the whole resembling in figure the letter T inverted;
and the two flaps so marked out, are reflected. Sometimes a single
incision, from above the neck of the tumour to the lower border of it,
is sufficient to afford room for the after proceedings. For some years
past I have performed an incision along the course of the ligament
of Poupart, with another falling from it over the body of the tumour
like the letter T, with the transverse part a little awry. In cases
of very large femoral hernia, such as that seen on the next page, the
incisions, as in the large inguinal tumour, must be made over the
situation of the femoral ring, and to a limited extent. In this case
the symptoms had existed for eight days, and had been latterly very
urgent, there being profuse feculent vomiting, and great depression of
the powers of life. There was a large mass of bowel protruded: this
was all returned, and the patient, though well advanced in life, made
a rapid recovery. A cast was obtained after her death, which happened
several years afterwards. It is seldom indeed that femoral hernia
attains such a size. I have seen it in the male, however, nearly one
half the size of the swelling here shown. The tumour is often not
larger than a walnut, seldom exceeding the size of a small apple. One
layer is found covering the sac, furnished by the strong and dense
cellular tissue which occupies the space under the crural arch and
falciform process of the fascia lata: it is generally denominated the
fascia propria, and has been described improperly, it would appear,
as the sheath of the femoral bloodvessels; at the lower part of the
tumour it is generally wanting. It is carefully divided, so as to
expose the sac. This not unfrequently is thickened very considerably, a
quantity of dense fatty matter being intimately incorporated with it;
but in general it is thin, and appears of a dark colour, in consequence
of the bowel and effused bloody serum being seen through it. It is
opened with great caution, part of it being raised and touched with
the edge of the knife held horizontally, or nearly so. The aperture,
thus formed, is enlarged by means of the probe-pointed knife, which is
carried upwards along the forefinger of the left hand. Some recommend
that the sac should be left undivided, and that the stricture should
be relieved by passing the knife on the outside; others, that only the
neck of the sac should remain entire, and the stricture be attacked
also on the outside of the peritoneum. But this appears an unnecessary
and unprofitable precaution. The extreme difficulty of returning the
sac is now well known and generally acknowledged; indeed, reduction of
it, whether opened or not, is practicable only in recent cases. Its
neck, besides, is firmly constricted; and the bowel may and will remain
strangulated when returned along with its sac, for the peritoneum
long retains the contraction at its strictured point. The stricture
cannot be well relieved unless the neck of the sac is cut along with
the resisting fibres exterior to it. After the sac has been opened,
the forefinger of the left hand is passed up to the crural ring; and
it should be recollected that this opening is very small, even in most
cases in which a hernia of ordinary size has existed for some time. It
is capable of great dilatation, gradual however, so that, in very old
and large ruptures, it may admit two or three fingers easily. But in
general only the nail of the finger can be insinuated into it; and this
is a better and safer conductor for the knife than a grooved director.
The edge of the stricture is felt very sharp; the point of the finger
is turned towards the pubes, and along it a narrow, blunt-pointed,
curved bistoury is passed in close contact, and with the edge towards
the pubes; its mere point is pushed beyond, and then the position of
the blade is changed: its back is turned upon the finger. This slight
motion is of itself often sufficient to relieve the constriction on
the protruded parts, and permit their reduction; if not, a few more
fibres are cut by raising the handle of the knife gently from the palm
of the hand. The direction of this incision is towards the tuberosity
of the pubes, inwards and forwards. Thus only the crescentic portion of
the crural arch is cut; and the division of this produces sufficient
relaxation of the neighbouring parts. There is danger in cutting
directly forwards, particularly in the male, at least if the incision
be made to any considerable extent; there is a risk of wounding the
spermatic chord, and the obturator artery has also been met with in a
few instances coursing round the neck of the sac. This distribution of
the artery, however, is rare, and can occur only when the epigastric
and obturator arise by a long common trunk, and even then it may not
encircle the neck of a hernia, as I have witnessed. Occasionally a
vessel of considerable size passes round the opening, connecting the
epigastric with the obturator, when these arteries follow their usual
course; and this also may surround the neck of the sac. If vessels
should exist in this situation in a person the subject of operation,
as has not happened so far as I know, they would be felt by the finger
used to conduct the knife. And the bistoury should never be passed—for
there is no necessity for it—through the opening so far as to meet
with a vessel, even if awkwardly placed. The danger of cutting forward
and to any extent has already been spoken of; such incision can answer
no good purpose. The stricture is not in Poupart’s ligament—though at
one time it was proposed to cut this through without interfering with
the tumour at all—but in the crural arch underneath, and in a manner
independent of the strong tendinous chord and expansion. The crural
arch is formed by the junction of the fasciæ of the thigh and abdomen,
superficial and deep. It is inserted into the linea ileo-pectinea,
where the tendon of the external oblique has no connection, and is
strengthened by fibres from the internal oblique, transverse, and
recti muscles. The crural aperture formed by this arch is relaxed by
flexion and inversion of the thigh, and by relaxation of the abdominal
parietes. And this fact requires to be attended to, after operation
as well as during the taxis, so as to facilitate replacement of the
protruded parts.
The same attention to the state of the parts in judging of the
propriety or not of reduction after operation, and the same after
treatment, both general and local, is requisite in crural hernia as
in inguinal. When the parts are reduced, the edges of the wound are
brought together by means of a few stitches; a graduated compress, of
proper dimensions, is applied, and retained by a spica bandage. If
this is neglected, there is a risk of the parts again descending.
Afterwards large mild enemata are to be administered, and, after some
hours, purgatives, so as to procure copious and free evacuation of the
bowels. In many cases after reduction, the bowels cannot by any means
be got to act downwards. This seems sometimes to arise from a sort of
paralytic state of the fibres of the part which has been extruded and
compressed. Again, it often arises from an indentation of the coats
of the bowel at the point where they have been tightly embraced and
compressed by the sharp edge of the opening, as here represented.
The engorged and dark state of the upper portion of bowel contrasts
well with the lower, which is generally empty, contracted, and pale.
If the stomach continue unsettled, a sinapism may be applied to the
epigastrium, or solid opium exhibited. Subsequently it may be necessary
to bleed locally, or generally, or both; in other cases the strength
from the first requires support. After cicatrisation, a well adapted
truss must be constantly worn.
[Illustration]
Umbilical hernia is generally congenital. The tendinous parietes are
often deficient to a great extent, and there is consequently much
fulness along the umbilical chord. The plan of embracing such tumours
in children by ligature, as at one time extensively practised, is
now abandoned, there being much risk of peritoneal inflammation and
fatal issue. The surgeon is now content with reducing the hernia,
and applying a truss, to prevent displacement, as in other forms of
protrusion; and if this be done in early life, and the apparatus
carefully worn, the opening contracts, and the patient may ultimately
be cured. The tumour may become strangulated, though rarely in the
adult; it is generally large, and almost solely occurs in females. The
sac has no covering but the skin and cellular tissue and fatty matter.
A small incision is made through the sac and its investments, either
on one side of the tumour, or in the mesial line at its lower aspect.
The stricture is then divided with care, the parts reduced, the wound
approximated, and a compress applied. Opening the tumour throughout its
whole extent is hazardous and unnecessary. The same remarks apply to
the proceedings in cases of ventral hernia. In corpulent females the
tumour is sometimes scarcely prominent, and is only discovered as a
flattened cake through the fatty matter.
The contents of hernia are often in a very bad state, either
dark-coloured throughout, or studded with dark tender spots. Lymph is
often effused all over the parts, gluing them to one another, and to
the sac. This effusion, which generally takes place to the greatest
extent at the neck of the sac, is a wise provision made by nature
against the accidents of the disease; inasmuch as a barrier is thereby
formed between the cavity of the abdomen and the extruded parts,
preventing, in a great measure, the destruction of the latter from
affecting the abdominal viscera. For example, a portion of protruded
intestine sloughs, the feculent matter is effused, and, had not this
adhesion to the neck existed, the gut might have slipped back into the
abdomen, its contents would have escaped there, and a fatal result
would have been the inevitable consequence. Still, notwithstanding
the salutary effusion, the bowel may ulcerate at its upper part, and,
giving way within the belly, produce rapid death. The bowel, where
embraced by the stricture, is contracted and thickened, and dilated
above. At the lower part of this dilatation the coats are apt to give
way by ulceration, even after incision of the constricting parts and
reduction. The contraction does not disappear quickly. In some cases
it continues to such an extent as to keep up obstructions to the fecal
matter, and cause a fatal issue from this cause alone, as noticed above.
Often, on opening the sac, in long neglected cases, a discharge takes
place of fetid air and thin feculent matter, the bowel has mortified
either entirely or in patches; in the latter case, presenting
the appearance of having been perforated at various points. Few
constitutions can bear up under such mischief. In some, if an opening
be not made, the integuments slough, and the patient, rallying after
discharge from the bowel takes place, recovers after losing a portion
of integument, of intestine, and perhaps of omentum. In others, and
they constitute the majority, the system sinks, before discharge from
the bowel is effected, by sloughing of the external parts.
The surgeon is called on to operate in the worst possible
circumstances, provided the patient is not in articulo mortis. Even
after many days of feculent vomiting the bowels may be found tolerably
healthy. The sac must be opened carefully, and the stricture is to be
relieved without disturbing the adhesions that have formed. The bowel,
when dead, or evidently gangrenous, is to be opened, and the discharge
of feces by the wound promoted. If returned into the abdomen, the
sloughs will separate, in all probability, and feculent effusion take
place, causing death in a very few hours. Sometimes the patient lingers
longer than could be expected, and I have known a female survive
upwards of a hundred hours after the occurrence of effusion into the
abdomen, from the giving way of an ulcer in the stomach. The dressing
should be light, and the patient’s strength must be supported in every
way, by the mouth, and by the anus when the injured part is high in the
canal. The separation of the sloughs is to be encouraged. The extent of
sloughing need not dishearten the surgeon, for large portions of bowel,
several feet in length, have mortified, and the patients recovered,
with artificial anus, either temporary or for life.
In artificial anus, when this has followed upon destruction of the
bowel to a considerable extent, the intestine has contracted firm
adhesion to the hernial sac at the opening in the abdominal parietes;
through the opening in the bowel exterior to this the feculent matter
is discharged externally, and by the adhesion is prevented from being
effused into the abdominal cavity. The protruded bowel in which the
sphacelation has occurred may be said to be thereby divided into an
upper and an under portion,—one, the upper, discharging, the other,
collapsed and empty; these lie parallel to each other, in close
contact, and usually adhering, from the abdominal or crural ring
downwards, to each other, and to the hernial sac. The hernial sac
seldom sloughs entirely; in almost every case its neck remains sound;
to this remaining part the intestine adheres. The deficiency in the
integuments and cellular tissue, through which the feculent matter
escapes, gradually contracts, and the aperture in that portion of the
hernial sac which is exterior to the intestine also diminishes; but
at the same time dilatation takes place in the immediate vicinity
of the intestinal orifices, so that a funnel-like cavity is formed
for the evacuation of feces, extending from the opening in the bowel
to the opening in the skin—its narrowest part being at the latter
situation, its most capacious surrounding the intestine. The cellular
tissue intermediate between the integument and hernial sac becomes
condensed, and forms a membranous lining. By this cavity an imperfect
communication is established between the two portions of bowel, part of
the feculent matter returning through the lower intestinal orifice, and
part escaping externally. But this communication must be indeed very
imperfect at first, since the two portions of bowel lie parallel to
each other, and their coalescing sides form an acute angular projection
into this funnel-shaped cavity. The lower portion is necessarily much
diminished in calibre, being in a great measure unaccustomed to the
usual distension, and its collapsed orifice is retracted a little
higher than that of the superior. On account of these circumstances
feculent matter cannot pass straight onwards from one portion of bowel
to the other, but must first traverse the funnel-shaped cavity; and
even then it is but a small quantity that reaches the rectum. Indeed,
in most cases of artificial anus, nothing but occasional flatus passes
by the original outlet for weeks or months. After some time the
bowel retracts, but cannot leave the adhesion in the groin: by this
retraction the orifices may be brought in a more direct line with each
other, and the natural passage of the feces be somewhat assisted.
When one or more slight patches of discoloration are observed after
division of the sac, it may be returned, it being most probable that
the parts will recover after removal of the stricture. When any portion
has given way, of course no one can contemplate reduction; and when the
whole calibre has sloughed it is absurd to attempt separation of the
adhesions which must exist, dividing the external from the internal
parts.
In mortification of a protruded knuckle, or part only of the calibre
of bowel, the symptoms are at first severe. These are vomiting, pain,
and symptoms of enteritis; perhaps the bowels are obstructed for some
time, but evacuation again takes place, as happened in the following
remarkable and instructive case. A gentleman, nearly eighty years of
age, was, during the action of medicine, suddenly seized with pain in
the groin. A very small tumour was observed— he became sick—and when
I visited him for the first time two days after, he had no further
evacuations from the bowels, he vomited constantly bilious fetid
matter, and he began to complain of pain in the abdomen. Pressure was
kept upon the tumour, which protruded at the crural aperture, for some
time, with the effect of diminishing its size very considerably. On
returning in a couple of hours with Sir B. Brodie, with the intention
of cutting down upon the swelling, the bowels had been freely relieved,
the vomiting had entirely ceased, and there was not the slightest
vestige of tumour to be perceived or felt, on the most attentive
examination. The patient had a good night, but in the morning had a
recurrence of the symptoms: these continued, and a fatal termination
shortly occurred; still no tumour could be detected before or after
death. It was supposed that the obstruction might have been caused
by a continuance of the constriction of the bowel, where it had been
nipped by the stricture. On a post-mortem examination, there was found
an exceedingly small portion of the coat of the bowel still entangled
in the crural ring, whilst a larger portion, which bore marks of
having been protruded, was thus entangled, and confined to the spot.
The bowel, though not completely obstructed, was narrowed by the
confinement of part of its parietes.
[Illustration]
Abscess often occurs externally to a small swelling of this nature, and
on the giving way of the integument, matter, flatus, and thin feces
are discharged. A _fecal fistula_ remains for some time; but, by the
aid of lymph and granulations, the breach in the parietes of the bowel
is repaired gradually, the feces resume their natural course, and the
external opening heals.
When the whole calibre has sloughed, and even when a large extent
of bowel has come away, and there is still a chance of the patient
recovering from the artificial anus by natural means, after the lapse
of many months. As already remarked, the intestinal orifices retract,
and come more into a straight line. A mucous discharge occurs from the
lower bowels along with the passage of flatus, and at last part of the
feces is voided by the rectum. The discharge from the external opening
diminishes, and ultimately ceases, perhaps only a minute fistula
remaining, through which a few drops of fluid, sometimes feculent,
sometimes limpid, may occasionally escape. The funnel-shaped cavity
previously contracts into a narrow fistula. This desirable result may
be assisted and hastened by gentle pressure; and, after the feculent
discharge has nearly ceased from the fistulous opening, the healing of
this may be accelerated by the cautery lightly applied. It has been
proposed to destroy the projecting septum between the two portions
of bowel, either by ligature or by the pressure of forceps; but this
should not be attempted unless nature seems unable to effect a cure.
The former method consists in including a considerable part of the
septum in ligature, so as to induce condensation of the parts by
effusion of lymph, and destruction of the projecting portion. This has
not been found very successful. The application of forceps presents a
more rational expectation of cure. The external opening is dilated,
and the situation of the septum ascertained. One blade of metallic
forceps, with blunt serrated edges,—Dupuytren’s,—is passed into the one
intestinal orifice, and the other into the opposite; the handles of the
instrument are then approximated, locked, and fastened with a screw,
and by means of the last-mentioned part of the apparatus the degree
of pressure is regulated. Pain of the abdomen, furred tongue, loss of
appetite, sickness, vomiting, and constitutional irritation, generally
follow this proceeding, but gradually subside on the employment of
enemata and fomentations, and on lessening the pressure of the forceps.
The septum cannot long withstand the continued compression, and by its
destruction the chance of cure is greatly augmented. The proceeding is,
besides, not so dangerous as might at first be supposed; for effusion
of lymph takes place to a considerable extent above the part grasped
by the forceps, gluing the portions of bowel firmly to each other,
and forming a new barrier against any of the feculent matter escaping
inwardly. Attempts may be made to repair the loss of substance in the
skin by paring the edges of the opening, and affixing a flap taken from
the neighbourhood.[45]