Part 55

Almost all the viscera of the abdomen and pelvis are liable to protrusion—the stomach—the spleen—the omentum—the great and small intestines, and even some of their most fixed parts—the ovaria—the bladder. Also, right portions of the viscera occasionally escape on the left side of the parietes, and the left at the right.

Hernial protrusion has received different names, according to the nature of its contents. When composed of a portion of intestine, it is termed _Enterocele_; _Epiplocele_, when composed of omentum; and _Entero-epiplocele_, when both intestine and omentum have escaped; and, as already observed, different names are also applied, according to the situation of the protrusion.

The inguinal and crural forms of hernia being the most common, will chiefly occupy our attention. The inguinal is divided into _true_ or _oblique inguinal_, and into _direct_ or _ventro-inguinal_. In the oblique, the protrusion passes along the inguinal canal. This course is in young persons short; but as the muscles become developed it is lengthened to about two inches, reckoning from the external ring to the funnel-like opening through the transverse fascia. The appearance of the swelling in this canal leads to diagnosis betwixt the oblique and direct hernia; but in chronic cases, this distinction is often in a great measure done away with. In large and old oblique ruptures the neck of the tumour is shortened, and the openings of the canal are approximated and more in a direct line. They are also immensely dilated, being often enlarged to such an extent as to admit all the fingers of the hand, when placed in a conical form,—and this even in the living body, the loose integument receding along with the tumour. The epigastric artery is situated behind the neck of the sac, on its inner side; and it is much displaced inwards in cases of old standing. The direct hernia passes through the parietes opposite to the external ring, and does not come in contact with the spermatic chord until it has reached that point. Its neck is short, and the epigastric artery is on its outer side. The coverings of the two tumours are different. Those of the oblique are such as the chord possesses—a prolongation of the transverse fascia, a covering from the cremaster muscle, fibres from the edge of the external ring, and the superficial fascia of the abdomen. The direct has only the last. A very old woman was operated upon in the North London Hospital a few days ago, for strangulated hernia of several days standing. The tumour was high in the inguinal region: on cutting down upon it, the tendon of the external oblique was found to cover it completely. The external ring was occupied by a mass of fatty matter, which probably had been displaced. The tendon was divided, and the sac, of considerable size, exposed. The opening through which the protrusion had taken place was very small, and situated a good deal to the mesial line of the internal aperture of the canal. The hernia was at the time of operation supposed to be ventro-inguinal. The patient was relieved for a time, but eventually sunk exhausted. An opportunity was thus unfortunately afforded of verifying the opinion formed. The hernia had two proper coverings, the superficial abdominal fascia and the tendon of the external oblique. The opening was inside the epigastric. The portion of bowel which had been extruded and returned was very tender, but it had adhered to the peritoneum, close to the place where it had been confined.

The oblique inguinal, when recent and small, is termed Bubonocele; but when large, it generally descends into the scrotum—oscheocele—of course exterior to the tunica vaginalis; and in females into the labium. The tumour often attains an immense size, from continued application of the causes that produced it,—laborious occupations, or straining of muscles in any way. When of long duration, and not attended to, it is not uncommon for the swelling to hang as low as the middle of the thigh, or even down to the knee. In such cases, the testicles often are wasted, and the penis concealed; indeed the skin of the penis, as well as of the lower part of the abdomen, is stretched over the tumour. Crural or femoral hernia is, on the contrary, seldom larger than a small apple. Sometimes, but very rarely, the tumour is of large dimensions. I have seen one containing the transverse arch of the colon, the omentum, and a yard and a half of small intestine. The tumour is represented some pages further on.

When a very large hernia remains always full, the cavity of the abdomen diminishes in size; in fact, it adapts itself to its contents; and this must be kept in mind when interfering with such cases.

Inguinal hernia most frequently occurs in males, the femoral in females; and the reason of this is obvious on comparing the size of the inguinal and crural openings in the sexes. In the male, the inguinal opening is much larger than the femoral; in the female, the femoral is the larger,—the inguinal is small, containing only the round ligament of the uterus. The causes of hernia act equally on both openings, and therefore it is to be expected that protrusion will take place where there is the least resistance, where the parietes are most deficient.

Hernia can seldom be mistaken for any other swelling, by one at all acquainted with his profession, and who makes his examination attentively. The history, and the mode of its appearance, are to be attended to. The swelling proceeds from above—at times it recedes on the patient lying on his back and making pressure on the swelling—a distinct impulse is communicated to it on exertion of the abdominal muscles, as in coughing—the tumour is generally elastic, and its neck can be felt extending from the lower abdominal aperture. Also, the two kinds, inguinal and crural, can scarcely be confounded with each other; the former is above, the latter below, the ligament of Poupart. It will be proper, however, to enumerate shortly the diseases for which hernia may be mistaken.

_Cirsocele_ may be confounded with inguinal hernia. Cirsocele, being a varix of the spermatic veins, enlarges on coughing and during the erect posture, like hernia; but in general the composition of the tumour can be ascertained by the feel which it imparts when handled,—the veins feel like a handful of earth-worms. Besides, the swelling is made to disappear, on emptying the dilated veins by pressure upwards; and, if the surgeon then firmly compress the inguinal aperture, the tumour will rapidly reappear, on account of the venous flow being interrupted, particularly if the patient exert his abdominal muscles, or assume the erect posture. Whereas, had hernia existed, the swelling could not have been reproduced; and, on the patient being directed to cough, a distinct impulse would have been felt with the finger. _Hydrocele_ of the tunica vaginalis may be confounded with scrotal hernia, if its distinctive characters be not understood or attended to. The pyramidal swelling presents an equal surface, fluctuates, and is generally diaphanous; its formation is gradual, commencing at the lower part, and slowly ascending; the testicle cannot be readily felt at the bottom of the scrotum; there is no swelling at the inguinal canal, and the chord is felt free; the tumour is not affected by the position, motion, or exertions of the patient. These circumstances plainly indicate the nature of the case. Bubo, sarcocele, and acute swelling of the testicle, are sufficiently distinguished from hernia by their situation, form, feel, and history, and cannot be confounded with it save by the profoundly ignorant. _Hydrocele of the spermatic chord_ is more likely to lead to deception when large; but it is generally small and circumscribed, involving the middle of the chord, leaving the inguinal aperture free, and the upper part of the spermatic chord distinct. Besides, whatever may be its size, its formation is always slow and indolent,—it is never capable of being pushed into the abdomen, and it is unaffected by those circumstances which contribute to mark hernia. But hydrocele of the chord and hernia may coexist, as in the following instance:—A gentleman had swelling in the course of the spermatic chord for many years, while in a warm climate. Bandages were applied, and great pain thereby occasioned. After his return to this country, pain in the belly and vomiting seized him on a Monday morning, and continued with more or less violence till the Sunday following. Then the vomiting became feculent, the belly excruciatingly painful and tender, the tumour tense, and the pulse weak. A physician opposed operative measures, having been convinced that his former complaint was a hydrocele of the chord. But I conceived that the symptoms warranted cutting down on the parts, and did so. A hernia was found containing omentum and a fold of bowel; a hydrocele of the chord lay alongside of it.

Crural hernia has been mistaken for bubo, and _vice versâ_. Lumbar abscess and varix of the femoral vein are also supposed to resemble it in some measure. The situation and form of the tumour in lumbar abscess is very different from those of hernia; and the mode of examination recommended in regard to cirsocele is equally applicable to the detection of dilated femoral vein. The distinctions between crural hernia and bubo are too obvious to require mention.

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.