In general there is a pain and uneasiness in the tumour; and, when it has been long down, the pain is often extremely violent, felt not only in the tumour itself, but over the whole abdomen. If the discharge of faeces is suppressed, inflammation soon comes on, the gut is thickened, the aperture through which it passed becomes too small for its return, and what is called a strangulation ensues. Herniae are consequently divided into reducible, irreducible, and strangulated. Reducible herniae are those in which the intestine on lying down spontaneously returns into the abdomen, or, at least, with the assistance of very gentle pressure, and may be retained there by the bandage styled a truss. Herniae are often irreducible from their size in consequence of inflammation; from the intestines containing hardened faeces, or flatus, which, from some obstacle at the ring, cannot be forced back. Sometimes membranous bands form across the sac, preventing the free motion of its contents; or the intestine is united by adhesions to the side of the sac. In each case the hernia is irreducible. The reducible hernia is more subject to strangulation than the irreducible; but the latter is much exposed to accidents, which are soon fatal.
The strangulated hernia is a disease of the greatest danger. When the omentum only comes down, the symptoms are those of inflammation and mortification. In this case it seldom happens that the faeces are retained; yet we have seen inflammation communicated from the prolapsed omentum to the intestines, and produce all the symptoms of complete hernia. In general, however, the pain and tension are not so great; the hiccough is less violent and constant. When the intestine, as well as the omentum, is strangulated, a violent pain is felt in the tumour, and a stricture round the body, about the navel, or somewhat above; frequent vomiting follows, succeeded by the evacuation of feculent matter. All evacuation downward is checked; the pulse is quick, and at first hard; the tumour red and painful, often cedematous; the abdomen tense and sore; hiccough soon follows; great anxiety appears in the countenance; the pulse sinks; and the patient appears to be expiring. Yet these violent symptoms will diminish, though the disease remain unchanged; and a flattering remission will come on, again to be succeeded by the distressing symptoms just described. These, at last, appear to yield almost suddenly: the patient is apparently easy, but the abdomen becomes more tense, the tumour of a darker colour; and death soon follows.
The symptoms of the true herniae apply in a considerable degree to prolapsed intestines in every part; and when we consider, in this detail, symptoms of prolapsed intestine, we shall scarcely fail to recognize the appearances wherever the accident happens; if, with these, we combine the injured functions of the part, and the chances of the intestines escaping into the cavity of the organ affected. See Bubonocele.
This accident being unattended with any division of the containing parts, the whole of the disease must be considered as a change of situation of the parts within. Were these immediately returned and kept in their place, the disorder would entirely cease; but in that preternatural situation they are pressed upon by the tendons through which they pass, and inflammation, with mortification, supervenes. This, however, is not owing to any change of state in the tendons, but merely to their natural elasticity, acting upon an increased and yielding subjacent bulk. The obstacle to the reduction of the prolapsed contents is, therefore, the increased bulk which they have acquired from inflammation in consequence of stricture, by which they are incapable of returning through the same passage at which they escaped.
If assistance is called in time, the return of the protruded parts must be attempted by such means as produce a contraction of the vessels and diminish the bulk of the solids: viz. cold, astringent, and stimulating applications. Emollients cannot relax the tendons, but often enlarge the bulk of the hernia, and render its reduction more difficult. Cold astringents should be immediately applied, and cold itself is an useful remedy. Ice, iced water, cold produced by the evaporation of vinegar and ether, are highly useful applications: at the same time these may be assisted by gentle but continued compression on the part with the fingers, or with small bolsters of soft linen cloth. By continuing these efforts for some time, the vessels are visibly less diminished, the swelling grows flaccid, the stricture gives way, and the disorder is removed.
When all proper attempts fail to reduce the contents of an hernia, the sooner the operation called celoto-mia is performed (see Bubonocele), the better; but when there are evident signs of the intestine being in a mortifying state; when the pulse and countenance sink; and when the tumour has lost its elasticity; Mr. Gooch recommends making an incision into the tumour, ample enough to evacuate the faeces freely, which may effectually remove the strangulation of the intestine at the abdominal ring, and then to treat the wound as a mortification, allowing nature to throw off the mortified slough. If it is doubtful in what condition the parts contained in the tumour are, the operation must be cautiously proceeded on, till we can see the state of the intestine: if that is mortified, it may be opened; and if the evacuation of the faeces do not effectually make way for the return of the parts, the abdominal ring must be opened by incision.
But, after replacing the hernial contents, to retain them requires very often the assistance of a bandage, or a proper compress. Mr. Pott observes,"all that can be done by surgery towards the cure of the hernia is, to replace the prolapsed body or bodies in the cavity of the belly, and to prevent them from slipping out again. When whatever formed the tumour is replaced, the surgeon hath done his part; the rest is nature's: whether the tendinous aperture will so contract as to prohibit a future descent or not is matter of uncertainty, and not to be known but from the event."