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 3½) 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.