The principles and practice of modern surgery

The term hernia of itself implies protrusion or escape of a contained organ or part through its containing walls, yet covered by some of them. Thus we may have hernia of the iris, of the brain, and the like; but when no particular part of the body is specified, by common consent the term is understood as implying hernia either of the intestine or the omentum, or of both. Such hernia may be either of congenital or acquired character, the former condition being permitted by some defect or abnormality in the abdominal parietes, the latter being the immediate or remote result of accident or of operation; and in the latter case they are referred to as traumatic or as postoperative. Of these the former is usually of rapid and the latter of slow development. Increased abdominal pressure doubtless has much to do with the occurrence even of a truly congenital hernia, as this would hardly develop were it not for the former. Such pressure may be the result of occupation, of pregnancy, or of certain morbid conditions—for example, those which cause constant coughing or straining at stool, or straining during urination—as from prostatic hypertrophy or phimosis, or such intra-abdominal conditions as tumors, which distort the abdominal walls, or accumulations of fluid which weaken them. Accident produces hernia mainly by causing the effects of pressure to be manifested in a brief space of time. Thus pressure or strain on abdominal muscles may part them in such a way as to permit the immediate appearance of a hernia, or its more slow development. The postoperative hernias are usually of the so-called ventral type, and occur most often after wounds which could not be immediately closed because of necessity for drainage, or in those which were closed in such a way as to permit of gradual warping or stretching of the resulting scar.

The surgical anatomy of hernia is described in works on anatomy. It is necessary, therefore, here only to remind the reader that the conditions existent in an old hernia may be different from those so described, for the original anatomical outlines may perhaps have long been lost and the original coverings more or less blended together so as to become indistinguishable. Particularly is it true of strangulated hernia that the more minute details are lost, and that in such cases there is great difficulty in the effort to recognize distinct anatomical layers and coverings. In old cases the sac—namely, the original peritoneum—may be greatly thickened, while in strangulated cases it will be discolored, perhaps even gangrenous, and will bear but slight resemblance to the original condition. The same is true of its contents, which may be adherent, strangulated, or gangrenous, according to circumstances.

The opening through which the hernia appears is usually referred to as the ring, to which, however, it may bear very little resemblance. Thus it may be an elongated buttonhole-like, or a warped, irregularly rounded sac opening, whose margins are thick or thin and easily distinguished or otherwise.

By all writers hernias are classified according to their anatomical characteristics as follows: Inguinal, indirect and direct; femoral, umbilical, ventral, diaphragmatic, gluteal or ischiatic, obturator, perineal, lumbar, sacrorectal, retroperitoneal (including the recently described paraduodenal or Treitz variety), and properitoneal.

Of these the most common are the inguinal and the femoral, the umbilical ranking next, while the other forms are rare.

Causes.

—Regarding the cause and nature of the common forms—namely, the inguinal and femoral—I propose here to introduce the views enunciated by Russell, of Melbourne, which seem to me to furnish the actual explanation for nearly all instances. This explanation refers to the congenital origin of the condition, even though it do not appear until the middle years of life. In the case of inguinal hernia it refers also to the persistence of the canal of Nuck, or of at least incomplete obliteration of the original vaginal process or prolongation of the peritoneum, which comes down with the migrating testicle and whose lower portion furnishes the cavity of the tunica vaginalis. It is more rational to explain the occurrence of hernia in connection with this preformed sac than by the view that there are so many instances of congenital weakness of the abdominal wall. That such weakness exists in many cases of hernia is undeniable, but this is to be regarded as the effect rather than the actual condition. From this last statement it follows also that there is great advantage in early operation, and in complete removal of the sac, which when performed early will not only cure the hernia but prevent the weakening of the abdominal wall itself. It follows, further, that the use of a truss, save possibly in the case of young infants, is an improper method of treatment. In other words, upon it is based the crux of the whole matter of successful treatment, i. e., operative removal of the sac.

It will be seen, then, that the cause of inguinal hernia is closely related with the cause of so-called congenital hydrocele of the cord (q. v.), the latter condition being one of sacculation of the canal, with accumulation of fluid; and it is interesting to recall that such sacculations are occasionally found in the ordinary so-called congenital hernias, when they are seen early, and before all anatomical surroundings have been merged together. The existence of a hernia implies the presence of a sac, and a congenital defect furnishes this latter, while the variations in the type of hernia are due mainly to the variations in the sac itself, i. e., in its location.

Russell has traced out the relations between the peritoneal pouches of the lower abdomen and the principal bloodvessels, and has shown how the former arrange themselves about the latter and are carried with them as they develop, assuming in consequence the type either of inguinal or femoral hernia, according as they are placed to the inner or outer and lower side of the same. He has insisted, and I think properly, that the variations observed in the clinical manifestations of a hernia are mainly determined by the size and the position of the sac, and that these depend upon its relations to the femoral and epigastric vessels, the associated sac and vessel being subject to the same vicissitudes in development. In this way the occurrence at one time of a congenital and at another of a so-called infantile type of inguinal hernia may be easily explained, as well as the differences between the so-called funicular and the partial form, and also the occurrence of the retroperitoneal or properitoneal forms, which, as variations are rare, and as clinical manifestations perplexing, but which nevertheless are easily explained when viewed in this light (Figs. 597 and 598).

Thus viewed, then, what are the relations of traumatism to congenital defects? When thus explained they seem to be as follows: By no means every individual who sustains an injury to the abdomen suffers from hernia, but when the parts are already weakened or prepared by the preëxistence of these congenital defects, then a small amount of strain or injury may serve to open them up and to produce a condition apparently due to accident which otherwise could not have occurred. The more I have studied the entire question the more I have come to the conclusion that hernias of the ordinary type, save in case of extreme violence, would not occur were it not for such a congenital prearrangement and tissue permission, as it were; so that we are justified in assuming that inguinal and femoral like umbilical hernias are really of congenital origin.

The Signs of Hernia.

—The signs of hernia include the existence of a tumor, usually at one of the common outlets, which may be variable in size, and fixed, changeable, or otherwise, according to whether it consist of intestine or omentum. To a hernial protrusion consisting of intestine alone may still be given the old term enterocele. One consisting of omentum is known as epiplocele. Hernial protrusions may attain tremendous dimensions, especially those appearing at the umbilicus, and some of these sacs contain perhaps the larger proportion of the intestine or even of the entire abdominal contents. Scrotal tumors, again, may attain large size, e. g., that of the individual’s head or even much larger. According to the nature of the contents such a tumor will be more or less resonant on percussion, and more or less compressible as well as reducible. Reducibility—namely, the ability to be returned to the abdominal cavity—is the most characteristic feature of a hernia and one possessed by nearly every such tumor, at least at its inception. It may, however, be lost.

Loss of reducibility, when occurring gradually, is replaced by what is known as incarceration, i. e., more or less complete fixation, at the same time without such pressure on bloodvessels as to produce necrosis. Incarceration may be the result of reduction in caliber of the hernial outlet, or of the formation of adhesions between the walls of the sac and its contents, such adhesions being common alike to omentum and large or small bowel. (See Fig. 599.) Strangulation is an acute process which may terminate either a reducible or an incarcerated hernia. It implies some sudden change, such as overcrowding of the bowel within the sac, or some peculiar kinking, by which intestinal caliber is shut off, as well as blood supply affected because of pressure, by which the vitality of the gut and of the sac is compromised or perhaps quickly lost. Strangulation, then, includes at least the possibilities and usually the simultaneous occurrence of acute obstruction of the bowel with more or less gangrene of the sac itself, as well as of the compromised gut.

Reducibility as an ordinary feature of hernia is one with which the patient himself is quite familiar, most patients with reducible hernias being able to effect reduction in the horizontal position, accompanied by some manipulation or maneuver. When in such cases reduction cannot be accomplished incarceration or perhaps strangulation has begun and the case immediately assumes serious proportions. Reduction is usually accompanied by a peculiar gurgle, as well as disappearance of the tumor itself, while the opening through which it has disappeared can usually be identified with the finger, by invagination of the scrotum, or by pressure over the femoral region. Such a tumor usually reappears when the patient stands, or particularly when he coughs or makes any straining effort, and the occurrence and recurrence of these phenomena clearly establish the diagnosis of hernia.

Irreducible or incarcerated hernias usually give some impulse upon the patient’s coughing, as do the reducible forms, yet in some cases they lead to more difficulty of diagnosis. Ordinarily in the male the question is mainly as between inguinal (or scrotal) hernia and hydrocele. In the latter there is a pear-shaped tumor whose apex should be found below the level of the inguinal outlet; a tumor which will fluctuate, whose shape does not change, which gives no impulse when the patient coughs, which is not influenced by pressure, even with the patient in the horizontal position. It is only in incarcerated or in peculiar types of congenital hernias, or in those combined, as they may be, with hydrocele, in which doubt should not be easily dissipated. While incarceration predisposes to acute obstruction it is not always followed by it, but may produce a more chronic type of constipation, with tendency to fecal impaction, because of the mechanical impediment to freedom of bowel motility. This condition is more frequently met in the aged.

Inflammation of the hernial sac, as well as of its coverings, leads to a condition described as inflamed hernia. It is essentially one of circumscribed cellulitis. It may be due to the irritation of a badly fitting truss or to other external causes. The inflammation may extend so as to involve the sac wall itself, and thus produce adhesions and later incarceration, or it may set up actual peritonitis, which may extend to the general abdominal cavity and terminate fatally. The more superficial and less acute forms are scarcely distinguishable from a local erysipelas which may terminate by abscess. Such a condition might be mistaken for one of suppurating bubo. Nevertheless the existence of the hernia itself should guard one against this error and make him extremely cautious in using the knife, even though it be necessary for the evacuation of pus.

Strangulated hernia has already been considered as the most common cause of acute obstruction of the bowel. Its possibility should be excluded in every case of this serious condition. While such are its general features, locally there is added to the general bowel obstructive condition that of more or less local destruction, which may vary from the presence of exudate, fluid or solid, with infiltration of adjoining tissues, to the most prompt and disastrous consequences of venous stasis, namely, extensive gangrene, which, involving first the bowel itself or the omentum, will later spread to the sac wall and its surroundings. In this instance around the loop or loops of gut involved will be seen a tight constriction or sulcus, above which the bowel will be more or less discolored and distended, while below it will be completely necrotic and perhaps actually sloughing. Minor degrees of strangulation may produce conditions which would lead up to this, but have not yet actually reached the stage of gangrene. Around such bowel will be found more or less fluid, the result of transudation, which will be swarming with bacteria and often offensive. The sac wall closely corresponds in appearance to that of the bowel, and everything about the sac and its contents will be infected and contaminated with bacteria, often of most virulent activity. The gangrene may involve an area of exceedingly small size, or the entire contents of the hernial sac. In the former instance the condition is comparatively simple as compared with the latter, which may require resection of several feet of necrotic bowel. The proper treatment of these conditions will be more fully dealt with below (Fig. 600).

Symptoms.

—The symptoms of strangulation are those of acute obstruction, plus the local evidences of a hernia, usually with added pain and tenderness, sometimes acute. These symptoms may come on as the result of strain or accident or without any known cause. Their intensity will depend in some measure upon the completeness of the blood stasis and the rapidity of the consequent gangrenous process. The latter may vary in degree. Thus the death of the compromised bowel may be practically determined within a few hours or within two or three days. The hernial tumor, within which strangulation has occurred, becomes more tense and incompressible, and, at the same time, more tender. Sometimes there is marked augmentation in volume; at other times this changes but little. So soon as a loop of bowel has lost its blood supply and become actually necrotic it will have also lost, when exposed, all of its luster or “sheen,” and will appear not only black and lusterless, but will be more or less offensive in odor, and of extremely septic character. The surrounding fluid will be found swarming with bacteria, and will seriously and perhaps fatally infect anyone inoculated with it.

Concerning the color of the exposed bowel and its appearance, it is a fairly safe rule to follow that gut which has not lost its luster, even though darkly discolored, is still viable, and may with safety be returned to the abdomen, which is probably the safest place for it; but when its sheen is actually lost the case becomes one either for resection or for artificial anus. It is possible that such a case may be seen only after absolute necrosis and fecal escape have occurred. When actual sloughing is thus met it is a question for resection or some other expedient.

Varieties of Hernia.

Inguinal Hernia.

—The inguinal form of hernia comprises nearly four-fifths of cases in males, a much smaller proportion in females. The hernial protrusion is always through the external abdominal ring, either by way of the inguinal canal, which it enters through the internal ring, or directly through the abdominal wall. The former is called indirect, the latter direct. Such a hernia is considered complete or incomplete according as it descends below the lower margin of the inguinal canal. An incomplete and direct hernia is often referred to as bubonocele. (Fig. 601.)

Holding the views above enunciated, regarding the congenital origin of practically every inguinal hernia, it is necessary to pay less attention to the distinctions insisted upon by the earlier authors concerning the congenital, the infantile, or the encysted forms of hernia, which depend upon the extent and degree of closure of the vaginal process or the canal of Nuck, which is carried down with the testis during its migration from the lower margin of the Wolffian body, and which is normally obliterated at birth. Nevertheless these conditions, however explained, are actually met during life and are represented by the diagrams seen in Figs. 602, 603 and 604.

In the female the canal of Nuck is a matter of minor importance, containing only the round ligament. Nevertheless along it may proceed an indirect inguinal hernia corresponding to that in the male.

The so-called acquired indirect hernia, according to the above views, would not occur were it not for the opportunity—as it were, the temptation—already afforded by some deviation of the peritoneal arrangement in this locality. In these cases, however, the sac appears to be new and is pushed along the inguinal canal anteriorly to its normal contents. This may be the result of violent strain, or of one which is apparently disproportionately small, but frequently repeated.

Direct inguinal hernia is generally an occurrence of adult life, takes place commonly as the result of accident, is a direct protrusion through the abdominal wall at the triangular weak spot, whose outer limit is the deep epigastric artery, with the obliterated hypogastric artery to the inner side and Poupart’s ligament below, i. e., the so-called triangle of Hesselbach. This hernia appears always at the external ring, from which it may descend and become scrotal.

With complete or scrotal hernia there is usually little difficulty of diagnosis (Fig. 605). An incomplete hernia, protruding at the external ring, covered with considerable fat, and perhaps shifted a little in position, is sometimes hard to distinguish from a hernia through the femoral opening. The inguinal form escapes above Poupart’s ligament, the femoral always below it, and Poupart’s ligament is to be located by a line drawn from the anterior superior spine to the spine of the pubis. The inguinal forms are usually nearer the middle line. If the epigastric artery can be identified, either before or during operation, the character of the hernia will be promptly demonstrated by its relations to the neck of the sac.

Hernial protrusions give a familiar impulse on coughing unless the incarceration of an epiplocele may mask this feature. By it they are to be distinguished from hydrocele, varicocele, aneurysm, undescended testicle, and the like.

Femoral Hernia.

—Femoral hernia is much more common in women than in men, and constitutes about one-tenth of all cases. This form is also nearly always congenital in the above sense, and is particularly liable to strangulation. It escapes through the femoral ring into the femoral canal, to the inner side of the femoral vein, and then, passing forward through the femoral opening, finds its direction of least resistance upward. In consequence a loop of bowel thus escaping from the abdomen may first pass downward, then forward, and then upward, which will illustrate the futility of the ordinary methods of taxis in the effort to reduce it by manipulation. These hernias are usually small, hence their greater danger. These cases have especially to be differentiated from psoas abscess, from inguinal lymphatic enlargements, and tumors. If the sac be entirely filled with omentum diagnosis is often difficult.

Umbilical Hernia.

—Umbilical hernia is primarily permitted by failure in obliteration of the opening at the navel for the omphalomesenteric duct and for the urachus. Originally small, it may yet assume enormous dimensions. Though actually of congenital origin, as just stated, it may not be discovered until the later years of life. It occurs much more commonly in females than males, and usually in connection with a large deposit of fat in the abdomen, by which its existence, or, at least, its limits and dimensions are masked. Through the umbilical opening, which in the majority of cases is small, may escape other of the abdominal viscera, as is shown in Fig. 606, illustrating hernia of the liver. Fig. 607 illustrates the pendulous form which many of these cases assume.

An infantile form (umbilical) is known, in which the actual protrusion does not occur until the infant is several months old, and which appears to be due to frequent strain, on a weak or incompletely closed fenestrum, by coughing, crying, efforts to expel urine through a strictured prepuce, and the like. These tumors at first are small and always intestinal. It is often possible to so adjust a small pad over these openings as to secure subsequent closure by natural processes. On the other hand, the forms which come on in later life, acquired during pregnancy, ascites, or in connection with excessive obesity, assume sometimes relatively enormous size. Here the hernial contents may be solely omental, but are usually at least partially intestinal. Strangulation occurs in a large proportion of these instances and incarceration is nearly always observed. Naturally, in consequence, the patient complains of gastric disturbances, as well as of chronic constipation, with frequent colicky attacks.[61]

Ventral Hernia.

—Ventral hernia is of two types—the spontaneous, usually epigastric, which is an omental escape in the middle line above the umbilicus, occurring most often in fat women, in whom it is likely to be mistaken for a hernia of ordinary umbilical type. By fixation of its contained intestine and omentum there is more or less dragging upon the upper abdominal viscera, with consequent disturbance of function.

Postoperative Hernia.

—Postoperative hernia often also spoken of as ventral, occurs through the cicatrix of the wound which has permitted it, whether this be in the middle line or elsewhere. It is an unfortunately frequent sequel of laparotomy wounds which have required drainage, but occasionally occurs in perfectly clean wounds which have closed satisfactorily in the first place, but which have subsequently parted because of unsatisfactory methods of bringing together their deeper portions. (See p. 778.) Consequently it should be sufficient here to remind the reader that the more accurate the method of approximating the margins, layer by layer, and effecting a complete and perfect union between them individually the less the tendency to this unpleasant sequel.

Postoperative hernia may be so small as to be kept under subjection with some form of abdominal support, or it may call for operations for radical cure, as do other cases. They are subject to the same dangers of strangulation of their contents.

Diaphragmatic Hernia.

—Diaphragmatic hernia may be congenital, as when occurring through a defect in this partition, or acquired, as when under stress or strain some of the abdominal contents are forced into the thorax, either through natural openings or through a rent or tear. Such escape may include but a small portion of bowel; in congenital cases one-half the abdominal contents have been found within the thorax. The left side seems more often involved than the right. Serious wounds of the diaphragm may be followed by this condition. Under these circumstances the thoracic viscera are more or less displaced, and the heart may be pushed considerably out of place. In cases with a history of violent accident the surgeon may more readily suspect and recognize the condition than in congenital cases, where anatomical relations have long been disturbed, but apparently more or less adjusted or compensated.

Pelvic Hernia.

—In the lower part of the pelvis, under rare circumstances, hernial protrusions occur either through the sacrosciatic foramina, in which case they are known as gluteal or ischiatic (Fig. 608), or through the obturator foramen, when they are known as obturator hernias, the latter occurring more often in stout women. Unless these constitute some form of recognizable tumor, or produce acute obstruction by strangulation, they will pass quite unrecognized. A perineal form of hernia is also known, which occurs in Douglas’ cul-de-sac, behind the bladder or uterus, the levator ani muscle being more or less disturbed, and the protrusion occurring somewhere between the labium and the anus. In such hernial sacs the ovary has been found, as well as intestinal loops, and the so-called ovarian hernia includes some anatomical anomaly of this kind.

Lumbar Hernia.

—In so-called lumbar hernia, which is very rare, the hernia escapes along the outer border of the quadratus lumborum muscle into the triangle of Petit. Such a tumor, usually small, may be easily mistaken for lipoma or for cold abscesses.

Other anomalous types of hernia may occur in connection with congenital defects of the bones or the less dense structures of the pelvis proper.

Retroperitoneal and Properitoneal Hernia.

—Retroperitoneal and properitoneal hernia are types which seem to corroborate the views already enunciated concerning the essentially congenital origin of the ordinary forms. The former implies a protrusion into an internal peritoneal pouch, and is usually found in the upper abdominal cavity in the duodenojejunal fossa, although it may also occur lower down on either side. It will not be recognized save by its effects, which will usually be those of acute intestinal obstruction, and even then will only be diagnosticated after the operation which the condition will necessitate. Hernia through the foramen of Winslow has already been mentioned in the chapter on the Small Intestines. (See Fig. 609.)

Properitoneal hernia implies usually the existence of a double sac, with a common opening, its inner portion lying between the peritoneum and the abdominal musculature, while its outer portion takes the usual position of the hernial sac, either the inguinal, the femoral, or the umbilical form. It may be suspected when reduction which has been apparently successful has later evidently failed. It occurs most often in the inguinal region, where it is usually referred to as inguinoproperitoneal hernia, and where it was first recognized by Parise, and later fully described by Krönlein. It may be with equal propriety called interstitial hernia, and is often associated with imperfect descent of the testicle, which perhaps has served to deflect the descending hernia in an unusual direction. The properitoneal sac is most often found between the internal ring and the anterior spine, although it may be directed downward and inward toward the bladder, or backward toward the iliac fossa. In size it is usually small as compared with the external portions. Its existence may be suspected when a patient with a hernia previously easily reducible suddenly develops strangulation, which is apparently relieved by taxis, only to recur a little later. So far as its radical treatment is concerned all that is necessary is the extirpation of the extra sac, with perhaps separate treatment of its neck, when dealing with the greater and more completely filled pouch in front (Fig. 610).

Littre’s or Richter’s Hernia.

—These terms have reference to strangulation of intestine in which, nevertheless, the entire lumen of the bowel is not completely involved, rather only a small area, which soon becomes sacculated, or perhaps by a diverticulum becoming involved in the occlusive and later gangrenous process. These forms are most frequently seen in women and at the femoral ring. They are peculiarly dangerous in that they produce symptoms which do not include those of total and acute bowel obstruction, and hence are often allowed to go unoperated until gangrene has already occurred. These forms, then, will produce signs and symptoms of partial strangulation, with incarceration, followed after hours or perhaps days by those of local cellulitis, with perhaps necrosis; conditions which when opened may expose gangrenous bowel and promptly become fecal fistulas.

Treatment of Hernia.

—Hernia is treated for three different purposes: for the relief of strangulation, i. e., as an emergency, for palliation, or for radical cure, according to the nature of the case and the wishes of the patient.

The relief of strangulated hernia becomes a measure of instant importance so soon as the condition is recognized, mortality being due to delay, practically every case being curable could it be recognized and operated promptly. The symptoms of strangulation, as repeatedly indicated, are those of acute obstruction of the bowel, including fecal vomiting with meteorism, and the local indications which may be trifling, as in very small hernial protrusions, or unmistakable, as in large hernial masses. The indication in every instance is to restore the occluded bowel to the abdominal cavity. Occasionally this may be effected by the method of manipulation or by taxis, which should never be thought of save at the very outset, and which may be aided by the local use of cold, or especially by the Trendelenburg position, which may be exaggerated. Under these circumstances, as Richardson has said, minutes are precious and delay adds materially to the danger, so that usually all non-operative methods are to be condemned.

Taxis.

—The principal danger in connection with taxis is that of doing harm to the occluded bowel by rough manipulation. The method includes a coaxing pressure in the proper direction, with more or less compression of the external mass, the effort being to gently persuade it back into the abdominal cavity. In this effort the temptation, especially among the inexperienced, is to use too much force, by which extravasation is produced, exudate increased, and the local condition in every way made worse. That which is possible during the first hour after strangulation has occurred may be impossible a little later, when edema and exudate have distorted the parts or cemented them together. The effort should not be prolonged, but rather very brief, and if after a very few moments no gain be made it should be discontinued.

Reduction “en bloc” is an unusual but ever-present danger. It implies forcing back the peritoneal sac as well as its contained intestine unreduced, so that while the external tumor is dissipated the actual condition of strangulation is not influenced. Its effect would be in no way to diminish the danger of the condition, but rather to more seriously menace the patient, under the supposition that reduction had been accomplished satisfactorily.

Two or three axioms in the treatment of strangulated hernia are imperative:

Very little time, if any, should be wasted in manipulation or taxis.

Taxis failing or there remaining any suspicion of reduction en bloc, open operation is imperative.

The time to operate is just after the diagnosis has been made and the condition recognized. Every hour of delay increases danger of obstruction and of gangrene.

Operations for strangulated hernia should thus always be done early and before much exudate or local disturbance has occurred, as when thus performed they may be combined with measures for radical cure, which are hardly to be thought of when infection has occurred. (See Plate LIV.)

Strangulated hernia, then, being always a dire emergency, is in nearly every instance best treated by herniotomy, whose principles are the same, no matter whether applied to inguinal, femoral, or umbilical hernia. By a suitably planned incision the sac is exposed. In the inguinal region this follows the general direction of the cord and inguinal canal. In the femoral region it is best to raise a flap, while in umbilical hernia, although the first incision may be in the middle line, it will usually be found necessary to make an elliptical excision of the overlying skin, in order that both it and the sac may be removed. Under conditions of long existent hernia, plus strangulation, the original anatomical conditions are much altered, and it is not necessary to waste time in the endeavor to recognize the various coverings of the sac. One cuts directly down upon it with such care that he may recognize it as he comes upon it, usually by its color and by the sensation of proximity to its strangulated contents. This is ordinarily not a difficult matter; all bleeding vessels should be secured before the sac is finally opened. Final and complete identification may be made by finding that the sac itself may be pinched up between the fingers or forceps, while the underlying contents slip away. Only when parts are bound together in exudate will there be difficulty in this regard. The surgeon should still proceed with caution, although the sac will usually contain sufficient fluid of transudation to protect against injury to the enclosed bowel. Nevertheless the greatest care should be observed not to wound the intestine, which sometimes lies very closely under the skin, especially in the middle line of an umbilical hernia, although there may be masses of fat on either side of it. Sometimes the sac distended with discolored fluid is itself mistaken for the bowel. Error can usually be avoided by following it upward and identifying its continuity with the surrounding tissues.

When opened its contained fluid may be found quite clear, blood-stained, purulent, extremely offensive, or even fecal, according to the relative age of the condition and the degree and results of strangulation. Under all circumstances it is advisable to disinfect the sac and its contents before endeavoring to release them. This may be done with dilute peroxide of hydrogen or with any ordinary irrigating fluid.

Within the sac, when thus identified and opened, may be imprisoned omentum or bowel, or both, in any degree of preservation from that which is almost normal, and with circulation but slightly disturbed, to that which is absolutely gangrenous. Congested bowel will nearly always be more or less discolored. So long as it is dusky or even almost black, but has not lost its luster, it may probably be safely returned to the abdominal cavity; but if green or if luster be gone, or if the contained fluid be distinctly putrefactive, then serious doubt as to its viability will arise. In case of actual perforation, gangrene, or fecal abscess there will be no doubt as to the danger of returning such bowel, and other measures should be adopted.

The viability of the bowel having been determined and the sac disinfected the location and degree of tightness of the constricting ring should now be determined. In inguinal hernia the constriction may occur either at the external or internal ring; in femoral hernia it is usually at the femoral ring; in umbilical hernia, at some portion of the umbilical opening; while in all three forms constriction may occur within the sac itself and with little reference to the ordinary hernial outlets; all of which needs to be clearly kept in mind. This identification is usually done with the tip of the little finger, gently insinuated and used as a probe. The operator who is sure of his methods does not necessarily need to expose the constricting ring in order to nick it or divide it, but he who is not as proficient should extend and deepen his incision until the parts are clearly exposed, so that he may be sure of not doing more harm than good.

Ordinarily it is necessary only to nick at one or two points the margin of the ring, which will feel much like a wire loop, and then to use the finger as a dilator, stretching and perhaps tearing, i. e., making the knife do as little and the finger as much work as possible, in order to so loosen up the constricted canal that by gentle taxis or manipulation reduction can now be accomplished. The text-books on anatomy give minute descriptions of the relations of these hernial outlets to important bloodvessels, with which even the student should be perfectly familiar. Nevertheless by following the subjoined rule, and never departing from the principle thereby indicated, the operator may safely proceed in practically every instance. This is to cut in the direction of the patient’s nose. The knife used for this purpose is ordinarily the herniotome, i. e., a blunt, slightly curved bistoury, with but a small exposed cutting blade, whose dull point is passed along the finger until the constriction is reached, and then, by the sense of touch, beneath and beyond it, until the wire edge of the ring rests upon the cutting part. The handle is then turned until this edge points upward and is moved with a gentle sawing action always in the above-specified direction, until the peculiar resistance is felt to have yielded. It may then be turned a little and another nick be similarly made. These nicks should not be more than one-quarter of an inch deep, after which the knife is withdrawn and the finger now made to dilate and tear. With these precautions there is very little danger of dividing an anomalously placed vessel.

Dilatation of the ring being now sufficient it is well to pull the hernial mass a little downward, in order that the condition of the bowel at the point of constriction may be exactly noted. It should therefore be gently coaxed into the wound, once more subjected to inspection, and then to disinfection. The surgeon should now determine what to do both with the bowel and the omentum. Omentum which is covered with exudate or darkly discolored, or surrounded by offensive material, should be first liberated, then ligated, above the original point of constriction, and the undesirable part removed, the stump being returned to the abdominal cavity. The bowel, if decided by above indications to be viable, may then be gently coaxed back if handled with care.

But gut which has perforated, or is so compromised as to be threatening gangrene, should not be returned into the abdominal cavity, but treated by resection, or by fixation and the formation of an artificial anus, decision depending both upon the condition of the patient and of the bowel. Some of these cases are too nearly moribund when operated to justify such procedures as resection, and are suffering too profoundly from the consequences of obstruction to make it advisable to do more than open the bowel for its immediate relief. Artificial anus is, therefore, the inevitable necessity in some forms of strangulation. When the bowel is gangrenous it is not necessary even to endeavor to draw it farther down into the sac, but it may be simply opened in situ.

Intestinal resection and suture instituted under these circumstances are essentially the same as those already described in the chapter on the Small Intestines. With the formation of an artificial anus there results the inevitable fecal fistula which will require subsequent operation, probably secondary resection.

In non-septic and favorable cases, the reduction having been accomplished, the operator then may proceed to extirpation of the sac and the closure of the hernial outlet, i. e., operate for radical cure, this being a modern extension and addition to the old operation for relief.

If obstructive symptoms should persist after operation the possibility of twisting of the intestine, or a possible reduction en bloc, may be feared, which is not likely to occur if the open part of the operating have been done thoroughly.

Clean cases of strangulation may be closed without drainage. In case of doubt, however, it is advisable to provide at least a capillary drain, while every case known to have been contaminated should be perfectly drained.