will protect the bowel. In one case in which Liston operated, he
tells us, "there was no possibility of pinching up the sac, either with
the fingers or forceps; it contained no fluid, and was impacted most
firmly with bowel; very luckily the membrane was thin; and, observing a
pelleton of fat underneath, I scratched very cautiously with the point
of the knife in the unsupported hand, until a trifling puncture was
made, sufficient to admit the blunt point of a narrow bistoury."[144] If
the sac contains bowel and omentum, it is safer to open it over the
omentum than over the bowel. When a small opening is made, an escape of
the contained fluid takes place, and then the sac should be slit up as
far as its neck by a probe-pointed bistoury, guided by the finger,
introduced to protect the bowel, whenever the opening is sufficiently
large. The forefinger must now be cautiously insinuated into the neck of
the sac, the nail being directed to the bowel, the pulp to the
crescentic margin of Gimbernat's ligament, and any constriction very
cautiously divided. The bowel should then be drawn down a little, the
constricted point carefully examined, and then returned or not,
according to its condition.
Two points require a brief separate notice:--
1. In what direction is the crural arch to be divided? Not outwards
certainly, on account of the vein, nor downwards, as the bone prevents
that direction. Is it to be upwards or inwards? Not upwards, for such
an incision would endanger the spermatic cord or round ligament, besides
greatly weakening the abdominal wall by the division, partial or
complete, of Poupart's ligament. Inwards then it must be; and little
more need be said about it, were it not for the occasional existence of
an abnormal course and distribution of the obturator artery.
[Illustration: FIG. XXXII.[145]]
The usual origin of this vessel is from the internal iliac, in which
case (Fig. XXXII. N O) it never comes near the sac at all. In certain
cases (1 in 3-1/2) it rises from the epigastric, and in a very few (1 in
72) from the external iliac. If rising from either of the two last, it
most commonly passes downwards at the outer side of the hernia, in which
case (Fig. XXXII. S O) no harm can possibly result; but in a few rare
cases, perhaps 1 in every 60 of those operated on, the vessel winds
round the hernia (Fig. XXXII. O), crossing at its inner side, and thus
may be (and has actually been) divided by a rash incision. With due
care, however, and by cutting a very little at a time, even this danger
may be avoided.
2. Under what circumstances is it possible or justifiable to reduce a
femoral hernia, without previously opening the sac? Only in certain very
select cases, where the hernia is recent, the constricting parts lax,
the general symptoms very mild, and where there is reason to believe the
bowel has completely escaped injury by compression or the taxis. There
are both difficulties and dangers in this so-called minor operation:--1.
_Difficulties_, For it is not easy to divide the constriction without
the assistance of the finger in the sac, and it is not easy to reduce
the contents with the sac unopened, except through a much freer opening
than is necessary when the bowel has been fairly exposed. 2. _Dangers_,
Of reducing sac and viscera, together with the strangulation still kept
up by tightness in the neck of the sac; or of supposing the sac is
emptied while a knuckle of bowel still remains in it, and is
strangulated; or, lastly, of reducing the intestine which has already
become gangrenous. It is very remarkable how very soon gangrene may come
on, in a case of a small recent femoral hernia, in which the fibrous
tissues constricting the neck of the sac are tense and undilatable. A
protrusion for eight hours has been sufficient to destroy the life of a
knuckle of bowel.
A note here on a certain condition very frequent in femoral herniæ,
which may occasionally give a good deal of trouble. Symptoms of
strangulation have been well marked, yet when the sac is opened
nothing is to be seen except a mass of omentum, perhaps tolerably
healthy-looking. To reduce this _en masse_ would be very unsafe;
it is necessary carefully to unravel it, and disengage the knuckle
of bowel which is almost certainly included in it, and which has
given rise to the symptoms of strangulation.
OPERATION FOR STRANGULATED UMBILICAL HERNIA.--The operation is
practically the same, whether the hernia is a true umbilical one, or one
which with more strict accuracy might be called ventral. True umbilical
hernia is a disease of infancy and childhood, being almost always
congenital, and the viscera protrude through the umbilical aperture.
This rarely requires operation, as it may generally be returned with
ease, and even cured by a proper bandage and compress. Ventral hernia,
commonly called _umbilical_, is generally a protrusion of viscera
through a new preternatural aperture in the fibrous tissues close to the
navel, may often attain a large size, is liable to strangulation, and is
not easily palliated or cured.
In either case the operation requires a very brief description. If the
hernia is small, under the size of a hen's egg, a crucial incision
through the thin skin which covers it will thoroughly expose the sac
when the flaps are dissected back. The forefinger should then be
inserted in the round opening, and the edges cautiously incised in
several directions, each incision however being very small.
If the rupture is large, a single linear, or a T-shaped incision,
exposing the base of the tumour, will be sufficient to allow the
requisite dilatation of the opening to be made. It is not at all
necessary in every case to open the sac of the peritoneum. If required,
it must be done with great caution, as the sac is generally very thin.
In cases where the hernia is chiefly omental, the sac should be opened,
lest a knuckle of bowel be inclosed and strangulated in the omentum.
OBTURATOR HERNIA is an extremely rare lesion, and a large proportion of
the recorded cases were discovered only after death. When diagnosed
during life and strangulated, some have been reduced by taxis, and only
a very few cases have been operated on, some with success. It is not
likely that a diagnosis could be made, except in very emaciated
patients, in whom pain at the obturator foramen was a prominent symptom,
and in whom it could be ascertained positively that the crural ring was
empty. An incision over the tumour, sufficient to allow the pectineus
muscle to be exposed and divided, is necessary. The hernia may then be
reduced without opening the sac, if recent; if of long standing, the sac
must be opened. One case is recorded by Dr. Lorinzer, in which, after
strangulation for eleven days, he opened the sac and found the bowel
gangrenous. The patient had a fæcal fistula; but survived the operation
for eleven months. Nuttel, Obrè, and Bransby Cooper have each diagnosed
and treated such cases.[146]
Other forms of hernia are so rare, and the treatment of each case must
necessarily vary so much in its circumstances, as not to require or
admit of any detailed account of the operations requisite for their
relief.
OPERATIONS FOR THE RADICAL CURE OF HERNIA.--The inconveniences and
discomfort caused by even the best-adjusted trusses or bandages, the
unsatisfactory support they afford, and the risk of their slipping and
allowing the hernia to escape, have given rise to many attempts to cure
hernia by operation.
Even to enumerate these would be quite beyond the limits of the present
volume; suffice it to classify a few of the most important of them
according to the principle involved in each, and then give a very brief
account of the method of operating which seems to be at once the most
scientific, least dangerous, and most permanently useful.
The question at issue is briefly this. We have, in a hernia, the
following condition:--The walls of a great cavity are at one or more
points specially weak, the contained viscera have protruded, either by
extension and stretching of a natural opening, or by the formation of a
new breach in the walls, and, in protruding, they have brought with them
as a covering a serous membrane, extremely extensible, highly sensitive
to injury, and, when injured, certain to resent it by severe, spreading,
and dangerous inflammation.
Do we desire to remedy this protrusion, we may act--
1. On the intestines themselves; but for all surgical purposes, they are
out of our reach. We cannot do more than, by diminishing their contents,
diminish their volume, and by position and rest reduce to the utmost
their tendency to protrude. This includes the medical and prophylactic
treatment of hernia, or rather of the tendency to hernia.
2. We may try what can be done with the _sac_ which the intestines have
pushed down before them. Can it be obliterated? If it can, perhaps the
intestines may be retained in their cavity. Very many plans of dealing
with the sac have been tried.
To cause obliteration of its cavity many methods have been proposed:--by
ligature of it along with the spermatic cord, involving loss of the
testicle, either by gradual separation, by sloughing, or by immediate
removal;--by cutting into it, and then stitching it up;--by constricting
it with wire, as in the _punctum aureum_; by pinching sac and coverings
up, by passing needles under them as they emerge from the external ring,
as Bonnet of Lyons did; by constricting sac alone with a double wire, by
subcutaneous puncture, as Dr. Morton of Glasgow has done;--by severe
pressure from the outside with a strong tight truss and a pad of wood,
as proposed by Richter; by setons of threads or candlewicks, as proposed
by Schuh of Vienna;--by injection of tincture of iodine or cantharides,
as by Velpeau and Pancoast;--by the introduction into the sac of thin
bladders of goldbeaters' skin, which were then filled with air, and were
intended to excite inflammation, as in the radical cure of hydrocele; or
by the still more severe method of Langenbeck, consisting in exposing
the sac by a free incision at the superficial ring, separating it from
the cord, and passing a ligature round the sac alone, leaving the
ligatured portion in the scrotum either to become obliterated or to
slough out. Schmucker of Berlin varied this, by cutting away the
constricted portion below the ligature.
The objections to these methods are various: the more gentle are
uncertain and inefficient; of the more severe, some involve mutilation,
by the loss or removal of the testicle; others, as those of Langenbeck
and Schmucker, are very dangerous and fatal, by the inflammation
spreading to the peritoneal cavity (20 to 30 per cent. died); while all
of these methods afford at best only temporary relief. And this is only
what might have been expected, for the sac was only a _result_ of the
protrusion, not a _cause_; and so long as the weakness and insufficiency
of the parietes of the abdomen remain, so long will the extensible
loosely-attached peritoneum continue to furnish new sacs for visceral
protrusions.
3. We have now only the canal left to act upon; and the operations on
the canal may be divided into two great classes:--
(_a._) Those in which the operator attempts to plug up the dilated
canal. (_b._) Those in which he tries to constrict it, by reuniting its
separated sides.
(_a._) Attempts to plug the canal have, in most cases, been made by
invagination of the skin of the scrotum and its fascia. These have been
very numerous and various in their adaptation of mechanical appliances,
but have all been designed with the same object. Dzondi of Halle, and
Jameson of Baltimore, incised lancet-shaped flaps of skin, and
endeavoured to fix them by displacement over the ring. Gerdy invaginated
a portion of scrotum and fascia into the enlarged canal, by the
forefinger pushed it up, and secured it in its place by a thread passed
from the point of his finger first through the invaginated skin, then
through the abdominal walls, endeavouring to include the walls of the
inguinal canal, causing the point of the needle to project some lines
above the inguinal ring; the same process being effected with the other
end of the thread on the other side of the finger, and the two ends
which have been brought out near each other on the abdominal wall, being
tied tightly over a cylinder of plaster. The ensheathed sac was then
painted with caustic ammonia to excite inflammation, and a pad put on
over all.
Signoroni modified this by fixing the invaginated skin by a piece of
female catheter, retained in its place by transfixion by three harelip
needles, tied by twisted sutures.
Wützer of Bonn, again, modified this, by substituting a complicated
instrument,
