Elements of Surgery

by Robert Liston

The same attention to the state of the parts in judging of the propriety or not of reduction after operation, and the same after treatment, both general and local, is requisite in crural hernia as in inguinal. When the parts are reduced, the edges of the wound are brought together by means of a few stitches; a graduated compress, of proper dimensions, is applied, and retained by a spica bandage. If this is neglected, there is a risk of the parts again descending. Afterwards large mild enemata are to be administered, and, after some hours, purgatives, so as to procure copious and free evacuation of the bowels. In many cases after reduction, the bowels cannot by any means be got to act downwards. This seems sometimes to arise from a sort of paralytic state of the fibres of the part which has been extruded and

compressed. Again, it often arises from an indentation of the coats of the bowel at the point where they have been tightly embraced and compressed by the sharp edge of the opening, as here represented. The engorged and dark state of the upper portion of bowel contrasts well with the lower, which is generally empty, contracted, and pale. If the stomach continue unsettled, a sinapism may be applied to the epigastrium, or solid opium exhibited. Subsequently it may be necessary to bleed locally, or generally, or both; in other cases the strength from the first requires support. After cicatrisation, a well adapted truss must be constantly worn.

Umbilical hernia is generally congenital. The tendinous parietes are often deficient to a great extent, and there is consequently much fulness along the umbilical chord. The plan of embracing such tumours in children by ligature, as at one time extensively practised, is now abandoned, there being much risk of peritoneal inflammation and fatal issue. The surgeon is now content with reducing the hernia, and applying a truss, to prevent displacement, as in other forms of protrusion; and if this be done in early life, and the apparatus carefully worn, the opening contracts, and the patient may ultimately be cured. The tumour may become strangulated, though rarely in the adult; it is generally large, and almost solely occurs in females. The sac has no covering but the skin and cellular tissue and fatty matter. A small incision is made through the sac and its investments, either on one side of the tumour, or in the mesial line at its lower aspect. The stricture is then divided with care, the parts reduced, the wound approximated, and a compress applied. Opening the tumour throughout its whole extent is hazardous and unnecessary. The same remarks apply to the proceedings in cases of ventral hernia. In corpulent females the tumour is sometimes scarcely prominent, and is only discovered as a flattened cake through the fatty matter.

The contents of hernia are often in a very bad state, either dark-coloured throughout, or studded with dark tender spots. Lymph is often effused all over the parts, gluing them to one another, and to the sac. This effusion, which generally takes place to the greatest extent at the neck of the sac, is a wise provision made by nature against the accidents of the disease; inasmuch as a barrier is thereby formed between the cavity of the abdomen and the extruded parts, preventing, in a great measure, the destruction of the latter from affecting the abdominal viscera. For example, a portion of protruded intestine sloughs, the feculent matter is effused, and, had not this adhesion to the neck existed, the gut might have slipped back into the abdomen, its contents would have escaped there, and a fatal result would have been the inevitable consequence. Still, notwithstanding the salutary effusion, the bowel may ulcerate at its upper part, and, giving way within the belly, produce rapid death. The bowel, where embraced by the stricture, is contracted and thickened, and dilated above. At the lower part of this dilatation the coats are apt to give way by ulceration, even after incision of the constricting parts and reduction. The contraction does not disappear quickly. In some cases it continues to such an extent as to keep up obstructions to the fecal matter, and cause a fatal issue from this cause alone, as noticed above.

Often, on opening the sac, in long neglected cases, a discharge takes place of fetid air and thin feculent matter, the bowel has mortified either entirely or in patches; in the latter case, presenting the appearance of having been perforated at various points. Few constitutions can bear up under such mischief. In some, if an opening be not made, the integuments slough, and the patient, rallying after discharge from the bowel takes place, recovers after losing a portion of integument, of intestine, and perhaps of omentum. In others, and they constitute the majority, the system sinks, before discharge from the bowel is effected, by sloughing of the external parts.

The surgeon is called on to operate in the worst possible circumstances, provided the patient is not in articulo mortis. Even after many days of feculent vomiting the bowels may be found tolerably healthy. The sac must be opened carefully, and the stricture is to be relieved without disturbing the adhesions that have formed. The bowel, when dead, or evidently gangrenous, is to be opened, and the discharge of feces by the wound promoted. If returned into the abdomen, the sloughs will separate, in all probability, and feculent effusion take place, causing death in a very few hours. Sometimes the patient lingers longer than could be expected, and I have known a female survive upwards of a hundred hours after the occurrence of effusion into the abdomen, from the giving way of an ulcer in the stomach. The dressing should be light, and the patient’s strength must be supported in every way, by the mouth, and by the anus when the injured part is high in the canal. The separation of the sloughs is to be encouraged. The extent of sloughing need not dishearten the surgeon, for large portions of bowel, several feet in length, have mortified, and the patients recovered, with artificial anus, either temporary or for life.

In artificial anus, when this has followed upon destruction of the bowel to a considerable extent, the intestine has contracted firm adhesion to the hernial sac at the opening in the abdominal parietes; through the opening in the bowel exterior to this the feculent matter is discharged externally, and by the adhesion is prevented from being effused into the abdominal cavity. The protruded bowel in which the sphacelation has occurred may be said to be thereby divided into an upper and an under portion,—one, the upper, discharging, the other, collapsed and empty; these lie parallel to each other, in close contact, and usually adhering, from the abdominal or crural ring downwards, to each other, and to the hernial sac. The hernial sac seldom sloughs entirely; in almost every case its neck remains sound; to this remaining part the intestine adheres. The deficiency in the integuments and cellular tissue, through which the feculent matter escapes, gradually contracts, and the aperture in that portion of the hernial sac which is exterior to the intestine also diminishes; but at the same time dilatation takes place in the immediate vicinity of the intestinal orifices, so that a funnel-like cavity is formed for the evacuation of feces, extending from the opening in the bowel to the opening in the skin—its narrowest part being at the latter situation, its most capacious surrounding the intestine. The cellular tissue intermediate between the integument and hernial sac becomes condensed, and forms a membranous lining. By this cavity an imperfect communication is established between the two portions of bowel, part of the feculent matter returning through the lower intestinal orifice, and part escaping externally. But this communication must be indeed very imperfect at first, since the two portions of bowel lie parallel to each other, and their coalescing sides form an acute angular projection into this funnel-shaped cavity. The lower portion is necessarily much diminished in calibre, being in a great measure unaccustomed to the usual distension, and its collapsed orifice is retracted a little higher than that of the superior. On account of these circumstances feculent matter cannot pass straight onwards from one portion of bowel to the other, but must first traverse the funnel-shaped cavity; and even then it is but a small quantity that reaches the rectum. Indeed, in most cases of artificial anus, nothing but occasional flatus passes by the original outlet for weeks or months. After some time the bowel retracts, but cannot leave the adhesion in the groin: by this retraction the orifices may be brought in a more direct line with each other, and the natural passage of the feces be somewhat assisted.

When one or more slight patches of discoloration are observed after division of the sac, it may be returned, it being most probable that the parts will recover after removal of the stricture. When any portion has given way, of course no one can contemplate reduction; and when the whole calibre has sloughed it is absurd to attempt separation of the adhesions which must exist, dividing the external from the internal parts.

In mortification of a protruded knuckle, or part only of the calibre of bowel, the symptoms are at first severe. These are vomiting, pain, and symptoms of enteritis; perhaps the bowels are obstructed for some time, but evacuation again takes place, as happened in the following remarkable and instructive case. A gentleman, nearly eighty years of age, was, during the action of medicine, suddenly seized with pain in the groin. A very small tumour was observed— he became sick—and when I visited him for the first time two days after, he had no further evacuations from the bowels, he vomited constantly bilious fetid matter, and he began to complain of pain in the abdomen. Pressure was kept upon the tumour, which protruded at the crural aperture, for some time, with the effect of diminishing its size very considerably. On returning in a couple of hours with Sir B. Brodie, with the intention of cutting down upon the swelling, the bowels had been freely relieved, the vomiting had entirely ceased, and there was not the slightest vestige of tumour to be perceived or felt, on the most attentive examination. The patient had a good night, but in the morning had a recurrence of the symptoms: these continued, and a fatal termination shortly occurred; still no tumour could be detected before or after death. It was supposed that the obstruction might have been caused by a continuance of the constriction of the bowel, where it had been nipped by the stricture. On a post-mortem examination, there was found an exceedingly small portion of the coat of the bowel still entangled