Gangrenous strangulated hernia; artificial anus; prolapse of bowel requiring intestinal resection; eventual recovery. (Preindlsberger.)
Strangulated hernia has already been considered as the most common cause of acute obstruction of the bowel. Its possibility should be excluded in every case of this serious condition. While such are its general features, locally there is added to the general bowel obstructive condition that of more or less local destruction, which may vary from the presence of exudate, fluid or solid, with infiltration of adjoining tissues, to the most prompt and disastrous consequences of venous stasis, namely, extensive gangrene, which, involving first the bowel itself or the omentum, will later spread to the sac wall and its surroundings. In this instance around the loop or loops of gut involved will be seen a tight constriction or sulcus, above which the bowel will be more or less discolored and distended, while below it will be completely necrotic and perhaps actually sloughing. Minor degrees of strangulation may produce conditions which would lead up to this, but have not yet actually reached the stage of gangrene. Around such bowel will be found more or less fluid, the result of transudation, which will be swarming with bacteria and often offensive. The sac wall closely corresponds in appearance to that of the bowel, and everything about the sac and its contents will be infected and contaminated with bacteria, often of most virulent activity. The gangrene may involve an area of exceedingly small size, or the entire contents of the hernial sac. In the former instance the condition is comparatively simple as compared with the latter, which may require resection of several feet of necrotic bowel. The proper treatment of these conditions will be more fully dealt with below ([Fig. 600]).
Symptoms.
—The symptoms of strangulation are those of acute obstruction, plus the local evidences of a hernia, usually with added pain and tenderness, sometimes acute. These symptoms may come on as the result of strain or accident or without any known cause. Their intensity will depend in some measure upon the completeness of the blood stasis and the rapidity of the consequent gangrenous process. The latter may vary in degree. Thus the death of the compromised bowel may be practically determined within a few hours or within two or three days. The hernial tumor, within which strangulation has occurred, becomes more tense and incompressible, and, at the same time, more tender. Sometimes there is marked augmentation in volume; at other times this changes but little. So soon as a loop of bowel has lost its blood supply and become actually necrotic it will have also lost, when exposed, all of its luster or “sheen,” and will appear not only black and lusterless, but will be more or less offensive in odor, and of extremely septic character. The surrounding fluid will be found swarming with bacteria, and will seriously and perhaps fatally infect anyone inoculated with it.
Concerning the color of the exposed bowel and its appearance, it is a fairly safe rule to follow that gut which has not lost its luster, even though darkly discolored, is still viable, and may with safety be returned to the abdomen, which is probably the safest place for it; but when its sheen is actually lost the case becomes one either for resection or for artificial anus. It is possible that such a case may be seen only after absolute necrosis and fecal escape have occurred. When actual sloughing is thus met it is a question for resection or some other expedient.
Varieties of Hernia.
Inguinal Hernia.
—The inguinal form of hernia comprises nearly four-fifths of cases in males, a much smaller proportion in females. The hernial protrusion is always through the external abdominal ring, either by way of the inguinal canal, which it enters through the internal ring, or directly through the abdominal wall. The former is called indirect, the latter direct. Such a hernia is considered complete or incomplete according as it descends below the lower margin of the inguinal canal. An incomplete and direct hernia is often referred to as bubonocele. ([Fig. 601].)
Holding the views above enunciated, regarding the congenital origin of practically every inguinal hernia, it is necessary to pay less attention to the distinctions insisted upon by the earlier authors concerning the congenital, the infantile, or the encysted forms of hernia, which depend upon the extent and degree of closure of the vaginal process or the canal of Nuck, which is carried down with the testis during its migration from the lower margin of the Wolffian body, and which is normally obliterated at birth. Nevertheless these conditions, however explained, are actually met during life and are represented by the diagrams seen in [Figs. 602], [603] and [604].