A reducible hernia, although not im mediately dangerous, leads to many un pleasant consequences, from its constant Increase in size, and the visceral derange. meats that ensue from this cause. It is also constantly liable to strangula tion.
In a strangulated hernia, the protruded parts become inflamed, and this affection is propagated over the rest of the surface of the abdomen. Hence pain of the part, and tension of the belly, are early symp. toms. An entire suppression of the fecal discharge is also every leading character. Nausea and vomiting ensue ; all the con tents of the stomach, and afterwards those of the intestines, down to the stricture, being rejected. The whole system is de ranged; there is great anxiety and rest. lessness, with a small and hard pulse, and cold extremities. At length hiccough supervenes, the pulse is hardly sensible, the respiration weak, and the whole bee dy is covered by a cold and clammy sweat. Mortification and death now speedily succeed. The intensity of the symptoms, and their duration before the occurrence of the fatal event, are modifi ed by numerous circumstances, as the age and strength of the patient, size of the rupture, closeness of the stricture, !cc. ; so that a case may terminate fatally within twenty-four hours, or it may be protracted for two or three weeks. Hence the strangulation has been distinguished into the acute and chronic.
The treatment of a reducible rupture comprehends the return of the protruded parts, and their retention within the ab dominal cavity by means of an appropri ate truss. Varibus proceedings were re commended by the older surgeons for producing a radical cure, as castration, caustic, the royal stitch, Ike. ; but as these expose the patient's life to the most im minent risk, without affording any great er chance of an effectual cure than the use of trusses would bestow, they have gone entirely into disuse. Herniary ban dages are of two kinds ; the elastic and non-elastic. The former are constructed with a piece of steel nearly encircling the body, and termed the spring, by means of which they maintain a constant pressure on the opening, through which the parts protrude.
If their use be continued for a suffi cient length of time, it even affords a prospect of a radical cure. Since the constant pressty-e of the pad of the truss keeps the neck of the sac empty, and thereby brings on a gradual contraction and obliteration of its cavity. Non-elas tic trusses are so inferior to the others,. that they are now universally laid aside. As the best constructed trusses will not lifford a certain protection from descent of the bowels, the ruptured person should avoid all great bodily exertions; and, if the hernia should descend, he should im. mediately go to bed, and send for surgi cal assistance.
As an irreducible hernia does not admit of the employment of a truss, the tu mour must be supported by a suspensory bandage ; and the patient, by temperance in diet, constant attention to the state of his bowels, and avoiding all great exer tions, must endeavour to obviate the risk of strangulation, to which he is constant ly exposed, and to prevent the increase of the tumour. Confinement to bed for a few weeks, with bleeding, mercurial me dicines, purges, and low diet, has some times caused irreducible hernia to go up ; but great caution is necessary in adopting such a plan.
In the treatment of strangulated hernia, we attempt first to replace the protruded which operation is technically termed the taxis. The patient should lie down, with his pelvis placed higher than the shoulders, with the thigh, in inguinal and crural hernia, bent and rolled in wards; the bladder being previously emptied, and a caution being given to ab stain from coughing, bolding the breath, &c. Gentle, pressure must now be made on the tumour, and increased to a certain extent, but if possible, not so as to give pain. A general pressure may be made with both hands, or the tumour may be grasped with one, while the other is placed at the aperture, and employed in facilitating the entrance of the parts, or in keeping up those which have been al ready returned. The pressure should be exerted according to the course in which the parts have been protruded; i. e. up wards and outwards in the bubonocele, backwards and then upwards in the fe moral hernia. Small hernia are the most difficult of replacement ; and the taxis succeeds also oftener in the early than the later periods of strangulation. It should not be persevered in when the rupture becomes painful. Mild purga tives and clysters should be used, even if We taxis succeeds. When we have not succeeded in replacing the parts, various means may be adopted in the treatment of a strangulated rupture. Those which are the most to be relied on are, bleed ing, the warm bath, clysters of the de coction or smoke of tobacco, and ice, or other cold applications to the part. The former remedy must not be used indis criminately, nor without a due attention to the patient's age and strength, nature of the symptoms, &c. Yet it should be employed with vigour when we have re solved on its use ; and a considerable quantity should be drawn suddenly from a large orifice, to induce fainting. This, with the warm bath, and the employment of ice, or of the freezing mixtures, made by the solution of salts, are the means to be employed first; and if they fail, the tobacco clyster, made by boiling one drachm of tobacco for ten minutes in a pint of water, should be instantly tried. If this does nut succeed after two or three attempts, the operation must be perform ed without delay. A smart purge of ca lomel and jalap will sometimes succeed in the early stage of strangulation, parti cularly in old and large hernia, where disorder of the bowels may have been the cause of strangulation, and where the symptoms are not very urgent. Opium is of use to allay the sickness. The sur geon should act with the greatest deci sion in these cases, and should particu larly avoid all unnecessary delay. He should try at once the most powerful means, and operate as soon as it is found that they will not succeed. Surgeons are now universally agreed, that the danger of the operation arises chiefly from its being deferred until the local or general disturbance have proceeded to such a height, that a favourable result can hardly be expected ; and that the chance of re covery is very considerable, when it is performed undermore favourable circum stances. We shall describe the operation in speaking of inguinal hernia.