HERNIA.
With the increasing safety and success of herniotomy, when the patient is young and strong, operation will usually be chosen as the best course of getting rid of the hernia and such appliances as may be necessary for its control, though when a hernia is reducible, a carefully planned truss may he fitted when the patient is in the lying posture; this if it is capable of preventing a descent of the intestine or omentum into the sac will suffice in most cases. The truss must as a rule he worn for life, though not unusually a case of hernia when treated from infancy by the con tinuous application of a neatly fitting truss may he found to be cured by the end of the second or third year.
Special circumstances may, however, be present in a given case which should determine the surgeon to do an operation for the radical cure of the rupture. Thus if the individual desires to enter into one of the public services or if his life is to be one involving intense muscular activity or strain he should be advised to submit to an operation; all femoral herniae in young subjects should be treated radically owing to the danger of strangulation. When a truss fails to keep up the bowel or where a prolapse of the omentum proves to be irreducible, the opening should be sealed up by the surgeon, and it is becoming the general routine practice to recommend a radical operation in all cases of hernia; occurring in children of all ages.
The reduction of a recent hernia is effected by taxis ; the patient should be placed in bed or on a couch, whose feet are to be elevated. The thigh should be partially flexed and the limb rotated inwards to secure as much relaxation as possible of the tissues surrounding the neck of the sac. The latter being grasped between the left fore-finger and thumb, gentle traction in a downward direction is made, whilst with a kneading move ment of the thumb and fingers of the right hand the tumour is slightly squeezed in order to reduce its bulk before being pushed up. No force in the ordinary sense of the term should ever be employed; the return of a knuckle of bowel to the cavity of the abdomen conveys an unmis takable sensation to the surgeon's fingers as the tumour slips suddenly upwards from his grasp, but a mass of omentum ascends gradually and without noise. If undue pressure is exercised the hernia may he reduced en bloc, the entire sac with its contents being forced within the abdominal wall, but still outside the peritoneal cavity. If symptoms of strangula
tion have already appeared only the greatest gentleness is permissible. The history of the case should be a guide; thus when the gut has been down for 24 to 36 hours and obstruction of the bowel and vomiting are present taxis must not be attempted. In such cases the first touch of the surgeon's fingers should convince him of the danger of rupturing the bowel by the application of any pressure. Tightly strangulated femoral herniae in young subjects are especially dangerous, but in elderly patients old inguinal ruptures may often be reduced when great skill and caution combined with general anaesthesia arc employed, even after symptoms of strangulation have appeared. A hot bath is often a useful adjuvant.
When taxis has failed the patient should be put to bed and arrange ments at once made for carrying out the operation of herniotomy; during the necessary delay the skin should be shaved and painted with Tr. Iodi and a large enema administered; it is needless to say that purgatives are always contra-indicated. In patients with Bright's disease or diabetes, where formerly operation was denied altogether, it is now done under local anaesthesia, the best choice being novocain per cent. and adrenalin, both in weak solution so that the infiltration method may be employed.
Herniotonzy.—The patient is prepared in the ordinary way for opera tion; the skin having been shaven and thoroughly cleansed with soap and water, is afterwards carefully sterilised by sponging with methylated spirit and then with Tr. Iodi. If an ancesthetic Jias not been previously tried, the surgeon, before proceeding with his incision, once more may try a gentle application of the taxis; the operation is sometimes satis factorily carried out under local anaesthesia. An incision should be made through the skin over the neck of the tumour and in the direction of its long axis; each layer of tissue on its exposure is to be carefully divided till the sac is reached. This must be opened with caution to avoid injury of intestine or omentum. The opening of the sac is usually accompanied by the escape of serous fluid, and its interior is smooth and shining and has its vessels running in the direction of its long axis. The latter point readily differentiates the sac from the intestinal wall.