The symptoms of strangulated intestine are ob stinate constipation, pain in the tumour extending from thence over the whole abdomen, aggravated on coughing, sneezing, pressure, or any move ment, nausea, vomiting, small, quick, and hard pulse, anxiety, restlessness, thirst, and general in flammatory fever. These are soon followed by hic cup, cold extremities, cessation of the pain, cada verous countenance, imperceptible pulse, feeble respiration, cold clammy perspiration and death.
Strangulated hernia is as liable to be confounded and complicated with other diseases as reducible hernia, so that we require to be very circumspect in our diagnosis; and probably, of all such affec tions, a swollen inguinal gland, accompanied with obtinate constipation, is the most frequent, and at the same time the least dangerous, for even, pro vided an operation is performed in such a case, no evil would be produced.
Let us suppose it to be purely strangulated in guinal hernia, the taxis is to be first employed, and if there be not much pain, it may be persevered in for some minutes; but if the reverse occurs, venesection even to fainting should precede the taxis, and if a warm bath can be procured, it ought to precede blood-letting. lie o ight to be bled while immersed in the water, and the taxis tried while in it. If he does not faint when the ordinary quantity for producing this effect has been abstrac ted, he ought to be raised to the erect attitude, and the instant syncope takes place, to be seated in the bath and the taxis employed. The tobacco enema may be combined with blood-letting to pro duce fainting in this disease, but is objectionable as it retards an operation. Purgative enemata should be employed. The time which is to be allowed in the employment of the preceding mea sures must be regulated by circumstances; more patients, however, fall victims to delay, than to an operation. We should operate immediately if the pain increases after giving a fair trial to the taxis combined with blood-letting, for perseverance in the taxis may produce suppuration, gangrene, and rupture of the intestine, and we allow the op portunity to pass of saving our patient by an ope ration. Small hernia are more difficult of reduc tion than large, in consequence of the smallness of the aperture. We must be careful not to be de ceived in reduction, for sometimes, only the con tents of the intestine are returned; in other in stances, only one of the viscera; at others, the in testine is still in the inguinal canal strangulated; in others, although the sac and intestine are re turned, still the neck of the sac continues to in carcerate the intestine; in others the omentum bridles down the intestine and strangulates it; in some ileus may be combined; while sometimes there exist two distinct herniae, and the contents only of the one are reduced. The symptoms con sequently ought to be our guide, but here also we may be deceived, for after reduction, although the patient is relieved from his immediate sufferings, inflammation may continue from the effect of the stricture. If therefore pain with vomiting still
continues after reduction, strangulation must exist, and an operation is required, and if after that ope ration these symptoms are not abated, either the omentum must be bridling down the intestine or ileus exist, and then the propriety of gastrotomy must be considered. When the mesentery within the abdominal cavity is the cause of strangulation, the case is named mesenteric hernia, and when the mesocolon, mesocolic, and that formed by the omentum may be termed internal ()mental hernia.
The operation to relieve strangulated inguinal hernia is performed by making an incision from a little above the tumour down to its lowest point, carefully through the skin and cellular substance; then pincing up with the fingers at the lowest por tion any cellular tissue, and cutting it horizontally with the scalpel, until the sac or intestine appears, for in some cases we have said there is no herniary sac, but when present, it is of a whitish colour, while the intestine is purple. We must likewise be on our guard in case of the spermatic cord run ning superficially to the peritoneal sac. The sac is next to be divided in the same cautious manner, when a bloody serous fluid generally escapes, and afterwards cut up to the seat of the stricture, with a probe-pointed bistoury represented in Fig. 8 of Plate DXVI. The portion of the muscle forming the seat of the stricture, which in a recent small hernia is commonly the transversalis, while in an old large hernia the external oblique, is now to be divided directly upwards with the same bistoury, but in some cases only the sharp-pointed bistoury can be admitted. The viscera are now to be re turned, reducing that first which protruded last; thus if both intestine and omentum are present, the former should be first replaced, and in doing so, considerable difficulty is generally experienced, in consequence of the action of the diaphragm and abdominal muscles forcing it out as soon as re placed. The edges of the wound are to be approx imated with sutures passing the needle through the muscles, then applying adhesive plaster, lint, and bandage. The nates are to be elevated above the level of the body when the patient is put to bed, and as mild diarrhoea commonly follows, a gentle laxative, as castor oil, should be given; and since inflammation frequently supervenes, if the patient has not lost much blood, venesection ought to be performed. The other remedies adopted in this affection are to be kept in view, and the diet should be low for many days. When the individual has recovered the operation, he must wear a rup ture truss for life.