Much is to be gained by observing the nature of the fluid which escapes upon the opening of the sac; if it is clear and odourless there is probably little injury to the bowel from 1.liH strangulation. A turbid, bloody or foul-smelling liquid shows that the constriction has already lowered the vitality of the intestine and permitted the sac being infected with the colon bacillus. In either case the sac cavity must be flu-shed with hot sterilised saline solution, after which the structures entering into the strangulating ring are to be carefully explored, layer after layer being divided, commencing in the dissection with the most superficial stratum and cautiously proceeding till the deeper fibres are divided sufficiently to remove the constriction without severing tissues which are of value in the final closing up of the aperture in the radical treatment of the hernia. The strangulation having been relieved the tumour is gently drawn downwards to bring into view the intestine at the line of constric tion. This is closely scrutinised after being well cleansed with warm saline solution and dried by a lint swab, in order to ascertain whether it has been only temporarily impaired or irretrievably damaged. If the purple discoloration speedily begins to lessen and the groove caused by the constriction shows any signs of vermicular contraction passing down wards when the bowel is pinched by the finger, the knuckle of intestine may safely be pushed up into the peritoneal cavity. On the other hand, should a lustreless and ashy-grey appearance of the strangulated mass lie evident, it must be accepted that the death of the parts below the constriction has already taken place or will certainly follow. This may be corroborated by pricking the tissues with the point of the scalpel, and no bleeding follows.
The gangrenous condition being thus obvious, the surgeon should draw down the loop as far as possible and resect it, cutting clear of the injured tissues, the mesentery being resected at the same time and the ends of the divided bowel united end-to-end or by natural anastomosis. It may be necessary in some cases to remove a few feet of bowel, the portion above the stricture which has been dilated and paralysed often requiring removal.
Occasionally the area of the gut destroyed by pressure may be so limited that it can be invaginated by a seromuscular or Lembert's suture without puncturing the mucous coat. When the bowel involved is the great intestine and the exhausted condition of the patient does not permit of a prolonged stitching operation the surgeon will feel compelled to leave the gangrenous bowel in situ after incising it in the sac, trusting to a second operation at a later date to close the resulting artificial anus.
Omentum may be returned like bowel when found to be healthy, but when gangrenous it must be first ligatured with catgut, which is made to transfix the pedicle, after which the mass is cut off and the pedicle with its occluded vessels is to be returned to the abdominal cavity. care
having been taken to insure that no small knuckle of bowel has been concealed within the omental tumour.
The final stage of the operation when the gut or omentum has been found to be in a condition capable of being returned is to proceed with the removal of the sac and closure of the hernial canal as in the radical operation for the cure of hernia.
After-treatment consists in rest to the bowel. but should abdominal distension persist a large enema may be administered after several hours, and when relief does not follow a dose of castor oil followed by r c.c. of pituitrin and an enema should be given in order to insure the restora tion of peristaltic action in the distended bowel. When vomiting per sists, and especially should this be foul-smelling, the stomach should be washed out, and this practice is often advisable before operation. In ordinary cases where no complications arise after operation, it is no longer considered wise or necessary to lock the bowels up with opium or astringents. An enema may be given after 24 hours, and a dose of Castor Oil 24 hours later. Should the symptoms of strangulation remain unrelieved after the operation an exploration of the abdominal cavity is imperatively demanded after a careful examination has been made of the usual sites for another hernia which had been overlooked. The same rule holds good when symptoms of obstruction remain after a hernia has been reduced by taxis, when the cause will usually be found to be a strangulation which has been unrelieved in a hernia returned en inasse.
Obstructed or incarcerated hernia occurs in elderly subjects who suffer from large irreducible herniae. If the symptoms do not yield to a skilful application of the taxis, herniotomy must be resorted to in order to avoid strangulation.
In some cases the surgeon will find it necessary to operate by opening the abdomen in the middle line, and after the removal of omentum the internal ring may be closed by a purse-string suture applied from above.
Irreducible hernia should be treated by the radical operation when possible, but in old subjects when the tumour is large a bag truss is usually all that is required.
Umbilical hernia is to be treated upon the same lines as hernia in the femoral or inguinal regions. When occurring in infants, strapping applied over a small flat pad and embracing the flanks is quite sufficient in the majority of cases to insure closure of the opening. In adults this form of hernia is very often irreducible, and may be kept from increasing by an abdominal belt containing a long strip of steel, to the centre of which is fitted a large pad which extends considerably over the margins of the hernial opening. Owing to the danger of strangulation and in carceration it is advisable to recommend a radical operation. When strangulation has already occurred there is no resource but herniotomy, and after relief of the constriction the opening must be closed and the sac excised.