Part 42

Patients with unreduced hernia are constantly in great danger; as bruising of the swelling, or accumulation of feces in the protruded bowel, are likely to occasion very unpleasant consequences. They are generally troubled with indigestion, flatulence, and constipation; a slight degree of constriction at the neck of the tumour produces an obstruction to the intestinal contents; the viscera in the sac have not due support and pressure, hence accumulations take place in them, and may be productive of serious and even fatal effects. No protrusion, in which these circumstances are likely to occur, should be allowed to exist, if possible. So afraid were the ancients of allowing hernia to remain unreduced, that it was their custom to cut all patients labouring under rupture who would submit to the operation; and this was generally performed by itinerant quacks. They returned the protrusion without opening the sac, and then the neck of the tumour was either stitched up, or tied along with or without the spermatic chord. The actual cautery, and the most powerful caustics, were also applied to the parts by some, and dreadful were the effects; yet after the neck of the sac had been destroyed, and perhaps the bone exposed and exfoliated, protrusion again took place by the side of the cicatrix. By many, castration was considered necessary for the cure of scrotal hernia. Such harsh measures were founded on erroneous and imperfect ideas of the nature of the disease, which are not often to be met with in the present day. Operations for unincarcerated hernia are not justifiable, and those who have operated in such circumstances give a very unfavourable account of the experiment.

The external applications employed to reduce hernia are various. Some are supposed to produce corrugation of the integuments, and contraction of the cremaster muscle, and thereby to force up the protruded intestine; others are of an astringent character, and their administrator may gravely believe and say, that by them he expects to tan the living scrotum, to reduce the hernia, and to present an insuperable obstacle to its reproduction. But all such means are visionary, and practically ineffectual; no external or internal remedy can attenuate and reduce the hernial sac, remove adhesion, or produce contraction of the tendinous and rigid apertures.

Herniæ are either reducible or irreducible. A hernia is said to 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.

The operation for inguinal herniæ is conducted as follows:—The patient 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.

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.

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.