Violent or prolonged taxis is attended with great risk; the bowel may be lacer ated or so severely contused that gan grene ensues. Often the sac has been ruptured by too forcible taxis. Methods of taxis which were perfectly justifiable twenty years ago when the mortality from operative treatment was very high, are no longer to be tolerated.
[Frikhoffer gives a mortality of 14.9 per cent. in 30S cases of femoral hernia successfully treated by taxis; 7.8 per cent. in 518 cases of inguinal hernia. WILLIAM R. COLE.V.] In cases that have been irreducible prior to strangulation—as is generally the case in strangulated umbilical hernia —taxis is clearly indicated. In cases where strangulation has lasted for twenty-four hours or longer, no attempt should be made to reduce the hernia.
Taxis should seldom be employed longer than from three to five minutes, and then only moderate force should be used. The application of an ice-bag (hot cloths are preferable in children and old people) may facilitate reduction. In in fants and young children it is a good rule, after an unsuccessful attempt to reduce the hernia by taxis, to immedi ately prepare for operation, and then, if reduction under an anesthesia be not successful, operation may be at once per formed without subjecting the patient to a second anaesthetization.
Number of cases in which the pro longed topical use of ether had resulted in the spontaneous reduction of strangu lated hernia. A compress moistened with ether was applied over the hernia and kept moist with ether dropped on to it. The reduction took place suddenly, and was sometimes accompanied by a cry of pain from the patient, followed immedi ately by a declaration of relief. The amount of ether employed was occasion ally as much as pint, and the duration of its use varied from fifteen minutes to two hours. Messinger (Jour. des Prati eiens, Nov. 10, 1900).
Operation for Strangulated Hernia.— IiccistoN.—Instead of the old incision over the most prominent part of the tumor, usually the upper scrotum, even now employed by many surgeons, it is much better to make the ordinary Bas sini incision, parallel to Poupart's liga ment, extending only slightly beyond the external ring. This incision is car ried down to the aponeurosis of the ex ternal oblique, which is slit up about two inches.
SAC.—The sac is next exposed by care ful dissection and opened by a scalpel or scissors. On opening the sac a smaller
or larger quantity of fluid almost always escapes. The character of this fluid should be carefully noted, inasmuch as this gives an important indication as to the condition of the bowel. If the bowel is simply congested, the fluid will be clear; if inflammatory changes have taken place, it will be turbid, but free from odor; if the intestine is gangrenous the fluid is sero-purulent and almost always has an intestinal odor.
A neglected point in the treatment of strangulated hernia is the necessity of emptying the bowel above the constric tion, thus relieving not only the con stipation, but relieving the patient of the accumulation of faces from which he has been absorbing various poisons. C. H. Whiteford (Brit. Med. Jour., June 16, 1900).
—Before attempting to reduce the bowel the con striction must be divided. This may be either the neck of the sac or the fibrous structures forming the external ring, which have already been slit up.
[The older writers on strangulated hernia have uniformly regarded the neck of the sac as the chief cause of the con striction, and, with the methods of per forming herniotomy formerly employed, it is easy to see how difficult and al most impossible it was to tell definitely whether the constriction was caused by the neck of the sac or by the external ring, both being cut at the same time by the old-fashioned herniotomy-knife. WILLIAM B. COLEY.] Strangulated hernia in infants is not unlikely to occur while the infant is at rest, and in infants vomiting it is so common that a strangulated hernia may easily he overlooked. The scrotum may be congested or inflamed very early, even though the bowel be but slightly damaged. Especial care is necessary in the operation on account of the extreme thinness of the sac and the very small quantity of fluid in it. The return of the bowel after division of the stricture may be helped by lifting the child's feet. The bowels are likely to act soon after the operation, and to be somewhat re ]axed for a few' days. In every case a radical cure should be made at the time of the operation, unless the child is so collapsed that it is dangerous to prolong the operation even for a few minutes. Paget (West London Med. Jour.. Apr., '97).