CHAPTER XI. STRANGULATED HERNIA, (Part 1)

CHAPTER XI. STRANGULATED HERNIA, What doctor in general practice has not had his experiences with strangulated hernia? And how many have escaped the comvietion that it is an emergency deserving its evil fame? But, after all, its sinister reputation our predecessors have bequeathed us and, along with it, interminable discussions aching the agent of constriction and the indications for taxis, ‘To-day we reverently lay aside those old notions, for we know that no other equally dangerous condition yields better results to appr priate treatment. By “appropriate treatment” is meant early epee tion, The indications for operation there is no need to discuss, fr operation is always indicated, xis is an exceptional procedure, permissible only as a tentative measure under certain well-defined restrictions; and even then be used with fear, for who can certainly tell that he has mot reduced = gangrenous and perforated gut; and who but the most experience may not be misled by certain forms of incomplete reduction ? ‘The danger from strangulated hernia was formerly supposed arise solely from interference with the circulation and the consequent gangrene of the incarcerated Joop, and the attention was contend chielly apon the mechanical clement. It wax perhaps logitienate upon that hypothesis to treat expectantly or by repeated efforts af taxis an incompletely strangulated bernia. But now it is definitely determined that the chief source of danger™ septic absorption, and in a given case long before the incarcerated bowel has ceased to be viable, the patient may be overwhelmed by teixina ay avirulent type. 11 is this systemic poisoning that makes: 4 hernia dangerous, and which especially makes the operation ous. If is for that reason that procrastination is so offen fatal Si sab DIAGNOSIS OF STRANGULATED HERNIA. 529 frequently it happens with these attacks that after hours of wititing, or after repeated efforts at reduction, the patient is finally turned over to the operator; and though the operation be of short duration and simple, yet the patient dies, for the reason that his powers of resistance were paralyzed by sepsis unsuspected. © He was a veritable victim of delay. The thought to be kept uppermost, then, in treating strangulated hernia is not so much that the bowel is becoming gangrenous as that sepsis is imminent, The diagnosis is not difficult, a3 a rule. Usually the patient is known to have a hernia; suddenly it becomes painful and irreducible; the bowels refuse to move and become tympanitic; nausea and vomiting ensue; and there are signs of circulatory depression. The general symptoms are, in fact, those of intestinal obstruction, The face is drawn and pinched, the lips white and the eyes sunken. There is a clammy sweat, The symptoms may all be mild at first, especially when the obstruction is not complete, or in the aged or debilitated, or if the bowel is surrounded by omentum which at first bears the brunt of the compression, Tt must be kept in mind that this mild onset may. be wholly deceptive. Tt may be necessary to distinguish between an inflamed and ob- structed irreducible hernia on the one hand and strangulated hernia upon the other; in the first, pain and yomiting are not so severe, there is no collapse, and an impulse in coughing can always be detected. If a hernia was not before suspected, a careful examination for one must be made in cases of intestinal obstruction, Small sciatic or obturator hernia: are casily overlooked. This is likewise true of small femoral hernia in fat subjects, ‘Torsion of the spermatic cord or strangulation of an undescended testicle may simulate strangulated hernia, but the indurated and very painful inguinal tumor, together with the cryptorchism, should suggest the nature of the attack. ‘As Senn says, the differential diagnosis between a suppurative lymphadenitis in the groin and a strangulated inguinal hernia may be very difficult. He points out the necessity for caution in using the knife if the inflammatory swelling is single and occupies the site of 1 femoral hernia. In such a case the supposed yland shou\d Wwe ay “ 530 STRANOULATED HERNIA. - proached by a careful dissection. If it proves to be a hernia no harm is done. An accumulation of peritoneal @uid in the imperfectly closed processus vaginalis in the very young may give rise to symptoms of strangulation, but strangulated hernia is rare in fnfants. In suck a case, inversion of the patient for a few minutes will empty the sac and clear up the diagnosis, As has been said the indication for treatment is operation as so0m ax the dingnosis is made. There are, however, exceptional instances in which judicious efforts at taxis may be applied without greatly prejudicing the prognosis. But it is recommended without enthe sfasm and only out of due respect to these circumstances of time and place which seem to preclude immediate herniotomy, Taxis and operation, then, represent the sole measures of refief Certainly no doctor at the present time would expect anything But harm from the use of drugs. As Senn says (Practical Surgery), no modern physician would fr 4 moment consider seriously the therapeutic value of nauseating enemata, or the internal use of relaxing antispasmodic remedies, 30 much relied upon in facilitating taxis before herniotomy was shors of its great mortality by the introduction of antiseptic: ob) Taxis —Taxis, or the reduction of a hernia by methodical manipa- lation jout instruments, is permissible only under these circum stances: (8) The case is scen soon after the strangulation began, the hernia is of moderate size; the abdominal symptoms are net severe, (b) The patient fs an old man debilitated, manifestly a poor mab ject for an operation; be bas had trouble before; it is only « few bourse since his hernia became irreducible. Under these circumstances use taxis, and it will not be dangerous if properly applied and mel repeated. The further proviso must be made that if ft fails an immediate operation mast beldanesimiann milder cates Sen adviex that taxis may sometimes be facilitated By) administering « dose of opium and giving a bigh enema. A Tull het bath in many instances has an excellent effect. In the severer cases a yencral anesthesia is always required. Before I = TAXIS YOR INGUINAL HERNIA. sat beginning the anesthesia prepare the patient for operation so that if taxis fails no time need be lost and a single anesthesia will serve both for the taxis and the operation. Chloroform is usually preferable to ether if it is expected that taxis will succeed. It permits a greater relaxation, Technic of Taxis: Inguinal Hernia.—Elevate the hips, flex and separate the thighs in order to relax the external ring. Grasp the tumor with the right hand (hernia on right side) so as to com press it unifarmly with the tips of the fingers and thumb. Seize the neck at the external ring between the thumb and forefinger of the left hand, While the right gently compresses the tumor, the left empties the gut by stripping in the direction of the external ring at first, and [ater along the inguinal canal The sole aim of this first manceuvre Is to empty the gut. The manipulations must be made methodically, without interruption and without force. If compres- sion reveals the presence of a doughy mass, it is omentum, and as it probably occupies the lower part of the sac it will be better to com~ press nearer the neck in order to deal more directly with the intestine. ‘Sometimes, to make traction on the tumor while the fingers at the neck continue the kneading will start the bowel contents toward the abdominal cavity. If the tumor under these manipulations grows smaller and softer, it is some guarantee of success. When the bowel is sufficiently emptied, it then becomes reducible and its return to the abdominal cavity is announced by a gurgling ot a marked sense of yielding. When the bowel is reduced, the omentum, if present, should be returned in the same manner. One should not persist if the mass lick and adherent for there is risk of rupture of an omental vessel, which may be followed by hemorrhage, all the more graye because unperceived. After the hernia is reduced the patient must be put to bed and no food by mouth permitted for at least twenty-four hours, Before wetting about, a truss must be fitted. If after ten or fiftecn minutes of gentle effort the hernial tamor remains unchanged in size and hardness, it is a waste of time to prolong the procedure. It cannot be said too often Yar reenter we 53? STRANGULATED HERNIA. tempts are injurious, becoming with each repetition more and mire harmful and illusory. Tt may happen that after the bernia has been apparently reduced the symptoms of obstruction still persist, or even Hf at first reliewet, appear again. The tympanites augments, the nausea and vomiting continue, and the signs of sepsis progress. It is evident that something isamiss. One of several things may have happened, bat ne time iste he wasted in conjecture, for only the operation which must follaw will definitely clear up the doubt. oo, 381, Stranded hernia reduced ee kml It may be that the hernial tumor has been reduced em masse ‘The hernial sac and its contents have been carried through the em ternal ring without having changed their relations and the constriction persists (Fig. 587). ‘This can oceur in recent hernia in which the sae is not adherent and is most common in the direct form of inguinal hernia. P It may be that instead of entering the peritoneal cavity the bernialed loop has entered a diverticulum of the ssc near the neck and ther becomes once more strangulated (Fig. 388) It may be that the neck of the sac has torn loose from the nested the sac and has been reduced with the gut, the sttamgulation sim being maintained (Fig. 389). -” _— = | OPERATION TOR STRANGULATED INGUINAL HERNIA. 533 Again, a rent may be torn in the sac and the gut escaping therefrom. pushes up between the peritoneum and the abdominal wall (Fig. 399). Finally the reduction may have been complete, but the gut was gangrenous or ruptured and a general peritonitis follows, due to the escape of the intestinal contents; or the peritonitis may even be due to the infection from the septic Huids in the sac. Femoral and Umbilical Her- wia.—These forms of strangu- lated hernia require the same modes of procedure as the in- guinal but are likely to present more obstacles. In the case of femoral hernia, if complete, the pressure must be made down- ward toward the saphenous opening at first, and then up~ ward along the femoral canal. Tn the case of umbilical hernia the pressure must be made toward the umbilical ring. Often the Trendelenburg posi- tion is helpful. The constant effort i first to empty the gut and then reduce it. In both these forms of hernia DSi seri vase, ajar) the gut may be enveloped by a mass of omentum which may not be reducible and thus gives rise to some doubt whether the gut has been reduced. Operation for Strangulated Hernia: Inguinal Hernia.—To re- peat, as soon as a hernia habitually reducible becomes painful and irreducible and is accompanied by the signs of beginning prostration, regard it as strangulated, and, aside from the exceptional cases in- dicated, operate at once. Do not wait for fecal vomiting for that is the last signal of exhausted nature—the precursor of deat's. dividing. No special instruments are necessary. Surgical Anatomy.—The special points to be remembered are the situation of the abdominal rings, the relations of the external asd internal oblique and transversalis myscles to the inguinal canal, and the location of the deep epigastric artery. ‘The external ring in the aponeurosis of the external oblique tes just above the spine of the pubes. The internal ring in the trane versalis tredectionty ‘tine, for before it can be reached the taal "Tle fata the ruptures sac must be opened, and that & am Pio. yyo.— lempectect - nounced by the escape of a character- istic sero-sanguinous fluid. ‘The greatest injury to the bowel i atthe site of constriction, which may be at the external ting, the Intersil ring, or the neck of the xac: The preparation of the ficld of operation must be painstaking ‘The pelvis must be shaved and scrubbed; the adjacent abdominal ail inguinal regions ard the scrotum must be thoroughly disinfected: ani the penis after cleansing wrapped in a sterile Kirst Step. Incision. . Exponure of the Soc.—Begin with a skein i extending {rom the internal ring down to the spine of the pubes @ scrotal hernia, down to the middle third of the scrotum (Fig | Go Aireetly through the skin snd \ayers of fat to the aponeurosie EXPOSING THE SAC OF A SYRANGULATED HERNIA. 535 of the external oblique, dividing the branches of the superficial epi- gastric artery. Expose the aponeurosis thoroughly and incise it from one ring to the other. It is easily recognized by the oblique direction of its fibers and its shiny look, ‘The lips of this wound should be caught up with forceps, especially at the external ring, to serve later as a land mark in beginning repair. F 10. s01.—Strangulate! inguinal hernia; primary incision, Once the aponeurosis is opened the sac is exposed and’ the next effort is to isolate it preparatory to fis incision. Separate it from the aponeurosis by careful blunt dissection around its whole circum- ference. Isolate the tumor up to the internal ring. If the sac is too intimately adherent to the aponeurosis it may be opened first. Second Step. Opening the Sac.—Catch a fold of the sac with dissect- ing forceps and cautiously divide the base of this fold with scissors ox scalpel (Fig. 392). It may be one of the connective mmue conerwogy J 536 STRANGULATED IERNIA. that is opened; divide It the full length of the wound a until finally the hernial sac ftself is opened, which yell be anno by a gush of bloody serum. Cautiously enlarge the openin, finger can be introduced, and on it as a guide, split the sac chose its neck (Fig. 393). When the constricting band is reached slip the finger under it, if possible, and divide it completely. If too tight for the finger, pass 2 grooved director as a guide. In some cases it may be better to use a herniotomy knife, but wherever possible avoid cut- Pra. 491-—Ovening the mcZol 5 straneulated nznie AG ven a the mae be pened & seteaatgromeres ting blindly. ‘The constriction must be freely divided So that the intestine can be readily drawn down for inspection. “This step is complete till that is possible It may happen that there is a second constricting band in such a case the forceps, which should always be attached | lips of the incision in the sac, are useful in palling it do what is to be divided can be seen. Third Step. Fxamination of the Intestine —It 4 of the portance that the site of the constriction be examined, for the: Jesions will be found there. Pull the gut down and obser of demarcation between the healthy and injured —— TREATMENT OF THE STRANGULATED LOOP. 337 One of several conditions will be present and the line of procedure will depend upon the one which is found. 1. The intestine is sound; that is to say, it has a uniform, dark violet color, most marked at the site of the constriction where it is lustrous. ‘There is no erosion of the serous covering. Dauching Pro. 993.—Dividing the constricting fibers of the strangulated " 29min ‘the pares showid te well expwed’ Gowers, ea the bowel with warm normal salt solution restores its tonicity, its rounded outline, and after a few minutes it assumes a redder color and is to be returned to the abdominal cavity. 2. The intestine is slightly injured; that Is to say, there may be several smal! zones of erosion exposing the muscular or even the mucous layer, Bury these areas with a few Lembert sutures, repair any injuries to the mesentery, and reduce. If the intestinal \ouy one, 538 STRANGULATED WERNIA. a methodical procedure may be required to prevent further injury to tissues already compromised. ‘The posterior segment of the kop should be reduced first, as it probably was the Jast to come dows; in the meantime the anterior segment must be carefully supported. ‘The least rudeness may result in a tear. 3. The intestine is deudtful; that is to say, it bas a color mottled Pro, 494. — examination of the stexagelated leon, (Vaan) and gray and purple. It does not recover its form under the dowel ing, but stays collapsed a attened. Under these conditions it may not be possible to say whether it is gangrenous or not, but it shoul not be reduced Treves, however, advises reduction under these circumstances, remarking (Operative Surgery, p. 534, Vol. IL) that whatever thearee ical objections to this procedure may exist, practice has shows that it may be safely carried out, awuming that this applies to = ee L sll TREATMENT OF GANGRENOUS Loo, $39 bowel which is not actually gangrenous, but in a condition which may be termed “doubtful.” Tt is remarkable to what extent these doubt ful intestines recover, The idea is that the peritoneal cavity is the most favorable site for recovery. If the operator is inexperienced and not certain that be can dis- tinguish between the bowel, possibly gangrenous, and that which has actually lost its viability, he must wait. Wrap the loop in moist gauze, and after twelve hours examine again. Tt may be gangrenous or it may be viable, lustrous, reddened, rounded, and impels the belief that it will become normal. With that belief, reduce it slowly and carefully, breaking up the slight adhesions which haye already formed. 4. The intestine is obviously gangrenous; that is to say,