Fig. 610
Properitoneal hernia. This illustrates also incomplete reduction of hernia. (Richardson.)
Littre’s or Richter’s Hernia.
—These terms have reference to strangulation of intestine in which, nevertheless, the entire lumen of the bowel is not completely involved, rather only a small area, which soon becomes sacculated, or perhaps by a diverticulum becoming involved in the occlusive and later gangrenous process. These forms are most frequently seen in women and at the femoral ring. They are peculiarly dangerous in that they produce symptoms which do not include those of total and acute bowel obstruction, and hence are often allowed to go unoperated until gangrene has already occurred. These forms, then, will produce signs and symptoms of partial strangulation, with incarceration, followed after hours or perhaps days by those of local cellulitis, with perhaps necrosis; conditions which when opened may expose gangrenous bowel and promptly become fecal fistulas.
Treatment of Hernia.
—Hernia is treated for three different purposes: for the relief of strangulation, i. e., as an emergency, for palliation, or for radical cure, according to the nature of the case and the wishes of the patient.
The relief of strangulated hernia becomes a measure of instant importance so soon as the condition is recognized, mortality being due to delay, practically every case being curable could it be recognized and operated promptly. The symptoms of strangulation, as repeatedly indicated, are those of acute obstruction of the bowel, including fecal vomiting with meteorism, and the local indications which may be trifling, as in very small hernial protrusions, or unmistakable, as in large hernial masses. The indication in every instance is to restore the occluded bowel to the abdominal cavity. Occasionally this may be effected by the method of manipulation or by taxis, which should never be thought of save at the very outset, and which may be aided by the local use of cold, or especially by the Trendelenburg position, which may be exaggerated. Under these circumstances, as Richardson has said, minutes are precious and delay adds materially to the danger, so that usually all non-operative methods are to be condemned.
PLATE LIV
