Elements of Surgery

by Robert Liston

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.

Returning the contents of the hernia into the abdomen is the only effectual means of counteracting the direful effects of strangulation; and the propriety of an early recourse to this measure must be quite apparent. It is indispensable, and no delay is warrantable. The means for accomplishing it must be varied, according to the state of the parts, the duration of strangulation, and the general symptoms. The most simple method, and that which should first be attempted in ordinary cases, is the taxis; that is, reduction by pressure with the hand. In this, the position of the patient is of importance; it should be such as effects relaxation of the tendinous structures through which the hernia has protruded, and through which it is to be returned. With this view he is placed on his back, with the shoulders and pelvis elevated, and in crural hernia the thigh is bent on the trunk, and turned towards the opposite side; thus the aperture is relaxed along with the fasciæ which compose it. Long ago, the positions into which the patients were forced for the cure of hernia were various, and generally awkward; they all tended towards more or less complete inversion of the erect posture, and thus it was supposed that the abdominal bowels dragged on those protruded, and thereby assisted reduction. But the viscera are equally pressed on in every position of the body; it is not they, but the external parts, that are affected by change of posture. During the attempts at reduction, the patient should be exhorted not to strain or resist, but to relax his muscles; and it will be well to engage him in conversation, that he may not have an opportunity of keeping his lungs distended, and thereby acting forcibly on the abdomen. At first the pressure should be general, applied either with one hand or with both, according to the size of the tumour, so as to diminish the contents. If air be heard gurgling at the neck of the swelling, the chance of success may be considered good, for a return of part of the bowel’s contents is thereby indicated. Then a gentle kneading should be made at the neck with the fingers of one hand, while with the other general pressure is kept up. The impression made is at first slight and gradual; but, when a portion of the bowel returns, the rest of it slips up suddenly. The return of omentum is always slow, and the last part requires as much manipulation as the first. The direction of the pressure must be varied according to the case. In inguinal and ventro-inguinal hernia, it is made in the direction of the neck of the sac; in the former upwards and outwards, in the latter upwards and backwards; and previously the body of the tumour should be brought into the same line with its neck. In crural hernia the pressure must first be made towards the centre of the thigh, so as to bring the whole tumour into the same direction with its neck, and then upwards. In umbilical, the pressure is straight backwards. Small herniæ, and those of recent origin, are with difficulty reduced; their neck is narrow, and the passage proportionately small; the crural are usually of this description. In all herniæ, after strangulation has existed for some time, and adhesions formed, particularly at the neck, reduction is almost impossible.

The taxis is to be neither attempted nor persevered in after the hernia has become tender and inflamed. No good can be done by it, and the patient’s chance of recovery by operation is much diminished. Even when no pain is felt in such circumstances, any degree of force must be prejudicial. Mortification of the bowels is often hastened in consequence of the taxis being unskilfully employed by ill-informed persons, who are often determined, at all risks, and at all stages of the affection, to accomplish speedy reduction of the viscera. The surgeon will take care to inform himself of all particulars—as to the duration of strangulation, the previous state of the tumour, if it was all, or only in part reducible, as to its size, &c.—before proceeding in any way. Great mischief is likely to accrue from the tumour being handled, perhaps roughly, by many people. If the taxis is gone about, however, in proper time, and in the right way, it ought almost always to prove successful. It is very desirable indeed that this should be the case, seeing that all the bad symptoms in ninety-nine out of a hundred cases instantly subside; whereas, after the reduction by incision, there is always great risk from the opening of the peritoneal sac alone.

Certain means may assist the taxis, but they should not be long continued or often repeated. Venesection can be employed only in strong plethoric patients, in the very first stage of strangulation, and before the patient is exhausted by the distressing symptoms. It is had recourse to in order to induce syncope, or an approach to it; during which general relaxation takes place, and reduction may be attempted with advantage. With that view the patient is placed erect, and a large orifice made in the vein of one or both arms, so that a moderate quantity of blood suddenly abstracted may have a powerful effect on the system. In several cases I have found this practice beneficial, but am inclined to say that, in general, it will not be followed with success. In a favourable case, one attempt of this kind may be made, but not repeated. In many states of the constitution, and in the latter stages of the disease, bad consequences must follow the practice. But in regard to it or any other remedy, it would be folly to lay down positive general rules; what may prove useful in one or two instances may answer very badly in the majority of cases that come under treatment. Local bloodletting can have no effect in diminishing the size of strangulated parts; though in inflammation of the contents of the tumour, without strangulation, no more powerful means can be employed.

Purgatives have been recommended with the view of extricating the bowel by increased peristaltic motion; but the symptoms will, to a certainty, be aggravated by their use. Purgative enemata can do little good: if in small quantity, they empty only the rectum; if large, they may reach the strangulated part, but will scarcely have the effect of extricating it.

Emetics, in full or nauseating doses, have been supposed to be indicated in this affection as well as in ileus; but there is in general enough of sickness and vomiting without them, and it is often difficult enough to allay the vomiting even after removal of the obstruction.

The warm bath is greatly trusted in by some, and in many cases it proves a valuable and useful auxiliary to the taxis. It acts beneficially by inducing general relaxation, or even syncope; during which, whilst all resistance of the compressing powers upon the contents is suspended, pressure on the tumour can be employed to good advantage. By steady perseverance, whilst the patient is in the bath, a great majority of strangulated herniæ may be reduced. But neither the general nor the local application of heat, or any other known means, save the edge of the knife, can relax tendinous apertures farther than can be effected by attention to position. Irrecoverable and most precious time may be wasted in preparing the bath; and for this reason such means should never be resorted to, unless they can be commanded at the shortest notice.

Fomentation can do no good. The apertures can be neither relaxed by heat, nor contracted by astringent applications. By the local application of heat, the size of the parts composing the hernia will be augmented, the flatus being rarified, and the effusion and engorgement encouraged.