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Strangulated Hernia

hernial, abdominal, sac, intestinal, treatment, contents and loop

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STRANGULATED HERNIA Intestinal coils are crowded into the hernial sac by the force of abdominal pressure; and if the hernial ring is narrow and the sphincter function relatively good, the hernial sac may easily become strangulated, thus preventing the return of the coils into the abdominal cavity. Accu mulation of feces, gas in the prolapsed loop, circulatory disturbances near the strangulating ring with consequent increase of the independent intestinal movements, aggravate the picture. The incarcerated loop is discolored and looks bluish red, the intestinal wall becomes permeable by its contents, the hernial fluid acquires an unpleasant sanguineous color, and unless the disturbing factor is removed there will be gangrene of the strangulated loop. Corresponding to these pathological changes, there are certain disturbances of the general and local conditions. The hernial tumor, which was at first reducible or at least soft, becomes hard and tender. In many cases a painful tumor develops in a place where none had been noticed before. The abdominal wall of the affected side is tense and tender. Infants will draw up their legs, crying with pain, and the abdominal pressure is increased. This is accompanied by nausea and vomiting, presenting the picture of intestinal occlusion. Unless there is speedy aid, death will occur from shock, sepsis, or perforating peritonitis; only in rare cases (about 5 per cent.) a kind of self-cure has been observed by closure against the abdominal cavity and perforation of the strangulated intestine into t he ichorous hernial sac.

I have not observed strangulation of the omentum in children. In adults the manifestations are less acute, and the intestinal move ments are not materially interfered with, in spite of a bad general condition.

The opinion, frequently entertained, that strangulated hernia is rare in children I believe to be erroneous.

Nor arc strangulations rare in older children with a slit-like hernial opening, especially in those where the hernia is associated with dis placement of the testicle, although it should be admitted that a large portion of these immix are spontaneously reduced. Thus it may happen

that a fair number of incarcerations in infants pass off untreated under the picture of violent colic.

The frequency of hernia also furnishes a measure for the degree of degeneration of the population, a fact which can be well verified in mountainous districts with their separate centres of population. In cities, industrial districts, and cretin valleys, hernia occurs frequently, while among the healthier mountain populations their frequency is much less. Their occurrence is disproportionately larger in boys than in girls, the proportion being 40 : 1, and this can be easily understood from the history of development.

The prognosis depends chiefly upon the treatment..

Many individuals go about with a congenital hernial tendency with out knowing it and without ever contracting a hernia. In 200 autopsies, according to Murray, there were OS cases with open processes vaginahs. Sudden exertion or great demand upon the abdominal musculature may cause the processes vaginalis to burst and allow the abdominal contents to enter. If the hernia has once prolapsed, there is little chance of a spontaneous cure, and this chance is lessened with each repetition of the prolapse. If there are abdominal contents present in the hernial sac, the only course for the sac is to become larger.

But whether a child has a true hernia or only a hernial predisposi tion, there is always the danger of strangulation, which is increased by various affections of the respiratory system (coughing), of the digestive tract (constipation, tenesmus), as well as by phimosis or physical effort.

different indications should be distinguished in the treatment.

a. Treatment of Strangulated soon as the diagnosis is made and the duration of the affection established from the history of the case, the proper treatment should be instituted without delay. If the strangulation has not existed for more than 12 hours, manual reduc tion by taxis should be attempted. A warm bath, and especially ether anassthesia, may materially facili tate the reduction by elimination of abdominal pressure (crying).

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