Colostomy pad and bag, worn as is a truss. (Kelsey.)
The colostomy opening in the abdominal wall should be made as small as practicable lest there occur not only more or less ventral hernia through the weakened outlet, but even, as I have seen in one case, a most extensive prolapse of the colon, in which two or three years after performance of the operation the colon could be made to prolapse to an extent of twelve or fifteen inches.
CHAPTER LI.
HERNIA.
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.