The symptoms which distinguish reducible her nia from the numerous affections with which it is liable to be confounded, are a colourless tumour in the region of one of the abdominal apertures, or even at any part of the abdominal cavity capable of being returned with the lingers, varying in size before and after meals, and in the mornings and evenings, influenced by coughing, and disappear ing in the horizontal position; and the patient is frequently troubled with colic. Its treatment con sists in reducing the protruded viscera into the abdomen, which is termed the taxis, and is per formed by placing the patient on his back, in the horizontal position, with his head and shoulders and knees so elevated, as to relax the abdominal muscles and the fascia lata femoris; and by press ing with the fingers upwards and outwards in in guinal hernia, and centrad upwards and inwards in crural hernia. Pressure first near the neck of the sac, and then on the body of the tumour, sometimes succeeds, but various other ways are recommended, which in our estimation appear fanciful and ab surd. Then applying a rupture bandage,. Fig. 24 of Plate DXVI. which ought to be worn day and night for life, together with the application of oak bark decoction for three or four months, (See Edina. Med. and Sur,. Journal, vol. xviii.) These will in nine out of ten cases effect a radical cure.
By irreducible hernia is understood the impossi bility of returning the protruded viscera into the abdominal cavity, in consequence of their having either remained so long down in the sac as to have become swollen, and hence too large, or contracted adhesions with the contiguous struc tures and the different viscera; the omentum is the most frequently so situated, next the caput ceccum, then the sigmoid flexure of the colon, and lastly, the urinary bladder. In this species of her nia, as the patient's life is constantly endangered, every attempt should be made to reduce it, and the bowels ought to be first unloaded by means of a cathartic; but we often fail, and if the mass pro truded be very large, the patient cannot suffer it to be returned, in consequence of the abdominal cavi ty having become habituated to a smaller quantity of intestine, and to persist may prove fatal. The patient must be exceedingly circumspect in his diet, his regimen, exercise, and all his conduct; and should support the mass with a T bandage or suspensary truss. Long confinement to bed, light spare diet, occasional bleeding, purgatives and glysters, have succeeded in returning the protru ded viscera; so also has the employment of trusses with hollow pads gradually reduced in size, to gether with confinement to bed; likewise rest in the horizontal position, combined with suspensary bandages progressively diminished in size. The application of ice has also succeeded. An opera tion has been likewise performed, but from the peritoneal inflammation which followed, it ought not to be done unless absolutely necessary. The
great Zimmerman nearly fell a victim to this ope ration, and the illustrious Gibbon preferred carry ing his load along with him to the grave. In some of these large irreducible hernia, so great a quantity of serous effusion takes place at the fundus of the sae as to require to be drawn off with a trocar and canula.
In this irreducible hernia, if the protruded intes tine becomes overloaded with feces, and an impedi ment be produced, or a fresh portion of this viscus or omentum be forced out, strangulation may oc cur; again, in the reducible hernia, if a greater portion of viscus be protruded, and the bowels be loaded with feces, which may be only a portion of the diameter of the intestine; while again, in a re cent hernia, if the aperture be too small to permit the return of the viscus, the same event may take place, strangulation may also ensue. Inflammation is soon excited, which causes thickening of the coats of the protruded intestine, and interruption to the circulation of the protruded omentum, an effusion of bloody serum in the herniary sac, coagu lable lymph on the intestine, with adhesion of the parts to each other, and ultimately mortification; while within the abdominal cavity, the inflamma tion extends to the intestines above the seat of the stricture, and to the peritoneum, both of which generally become coated with coagulable lymph, and more or less serous effusion is deposited. The strictured portion of intestine almost imme diately assumes a dark purple colour, in conse quence of its venous circulation being arrested, and soon becomes black and brown, and then rup tures; the portion of intestine above the seat of the stricture within the abdomen becomes also purple and black, approaching nearly to gangrene, while that below the seat of the protrusion retains its natural colour. When the omentum is the protru ded viscus, its circulation becomes also strangula ted, and produces inflammation, mortification, and death. If the patient has not previously fallen a victim to the derangement thus produced in his system, the strangulated portion of the intestine mortifies and ruptures, the feces are diffused in the neighbouring cellular tissue, which produce slough ing of the integuments, and are thus discharged, forming an artificial anus; or the integuments over the intestine inflame, mortify and ulcerate. In some cases the feces are so extensively diffused in the cellular tissue of the thigh, as to produce erysipelas phlegmonodes, and death. In those in stances where a portion of the diameter of the in testine is merely strangulated, the feces not only escape by the mortified aperture, but also descend naturally along the intestine to the anus.