If the hernia has been down but a few days and there are signs of local inflam mation, the patient should be kept in bed for a few days and an ice-bag applied. In using an ice-bag in these cases where the vitality of the skin is more or less impaired, one should always see that the ice-bag does not rest directly upon the skin, otherwise serious sloughing may ensue. Gentle taxis may be used during the course of this treatment, but it should be of only brief duration and never vio lent. In very many cases of irreducible hernia a larger or smaller quantity of serous exudate accumulates in the sac. This has been removed by aspiration. Still, while there is no objection to with drawing the fluid by means of a small needle if the hernia is purely omental, little is to be gained by this procedure. If the rupture cannot be reduced in one or two weeks, it may be regarded as per manently irreducible, and either opera tion or suitable mechanical support should be employed according to the nature of the case.
Diacready's tables show that 53 out of 85 cases of inguinal hernia were re duced within, on an average, of 51 days; 32 within, on an average, of 2.8 years.
These results show the advantage of operation, unless there is some decided contra-indication. WILLIAM B. Coi,Ey.] In irreducible inguinal and femoral hernia a very large number of patients are good subjects for operative treat ment; that is, they are under 50 years of age and the hernia is of moderate size, varying between that of a hen's egg and two fists. The results of operation in these cases are extremely satisfactory, and, as far as my personal experience goes, results have been as good as in re ducible hernia in patients of similar age. On the other hand, not a few cases, espe cially of umbilical and ventral hernia, are old epiploceles of very large size in very stout women with a great excess of fat in the abdominal walls. In such pa tients, as well as in those who are weak ened by disease of the thoracic or abdom inal viscera, operation should not be re sorted to, and our efforts should be confined to preventing the rupture from increasing in size. I have always be lieved that there was great risk in oper ating upon very large irreducible hernia. This opinion is supported by the early experience of Banks and the recently published results of Barker. I have known of several unpublished cases of this kind in which death resulted from the operation. In addition to the great risk there is little prospect of a perma nent cure.
Strangulated Hernia.
The term "strangulated" is applied to an irreducible hernia in which the loop of bowel is so constricted as to prevent the passage of faecal contents and to in terfere with the circulation.
The most common causes of strangula Lion are heavy lifting, severe coughing, and straining. It may also be produced by a blow or a fall.
Study of statistics of 1491 cases of strangulated hernia. Up to 20 years strangulation is rare, but gradually in creases until between 50 and 70 the largest number occur. The causes of strangulation are severe cough or bodily exercise, defecation, pregnancy, and diffi cult labor.
Strangulation occurs more frequently in crural than ingnina I hernia, 57.6 per cent. to 40.2 per cent., respectively; 51.2 per cent. of the hernial saes contain small intestine only, 5.4 per cent. only omentum, 29.8 per cent. contained both of these. Lipomata found in 9 per cent. of the eases. Oscar Ilenggeler ("Statis tics of 276 Cases of Strangulated hernia Operated upon in the University Clinic at Zurich from 1881 to ISO-i").
in irreducible hernia strangulation often results from inflammation or en gorgement of the contents of the sac, or from adhesions formed between the sac and its contents.
It is unnecessary to mention the va rious theories that have from time to time been offered in explanation of the way strangulation is brought about. The best and simplest explanation is that of venous engorgement: the walls of the veins being more compressible than the walls of the arteries, blood continues to flow into the imprisoned loop of bowel long after its return has been cut off. This produces great engorgement and rapid exudate of serum into the hernial sac, which makes reduction more and more difficult. The bowel first becomes of a brighter red, later bluish, then ma hogany, and, finally, just before gan grene sets in, of a dull slate color. The exudation, which at first is clear, after a longer or shorter interval becomes turbid. Gangrene may occur at varying intervals, depending upon the tightness of the constriction, the earliest time within which it has been observed being four hours and the latest two weeks. The fluid in the hernial sac frequently contains bacteria, although in the larger proportion of cases thus far investigated, it has been sterile.
Symptoms of Strangulated Hernia.— The first symptom is usually pain, re ferred to the irreducible tumor at the site of the hernial orifice. exam ination the tumor is found tense, and very tender on pressure; it gives no im pulse, or, at most, a slight impulse on coughing. If the strangulation has ex isted but a short time, the tumor will give a resonant note on percussion. Later this sign may be absent, owing to an accumulation of fluid in the hernial sac. In some cases the pain is referred to the umbilicus rather than the hernial tumor.