niated pari. Sometimes they complain of painful, difficult, or frequent
urination. A cystoscopic examination may clear up the diagnosis in some
cases. When we meet with the bladder during an operation for hernia it
may also be identified by the introduction of a Bteel sound through the
urethra.

Influence of Hernia upon the General Health. — Many individuals L r <> about
with a hernia of considerable size and quite ignoranl that the condition exists,
unless one of the complications of hernia occurs, li is possible for a very
large portion of the intestine to lie outside of the abdomen in a hernial >iu —
bo large a proportion indeed that there is no longer room for it inside the
abdominal cavity, and yet the individual may suffer from no symptoms other
than from the mechanical inconvenience of the large tumor. In mos
however, certain symptoms are produced, sooner or later, which call the atten-
tion of the patient to the abnormal condition. In more than ninety per cent
of the cases there is pain. If the hernia has followed a sudden violent muscu-
lar strain, the patient may have had a sudden sharp pain, referred to the lower
part of tlu' abdomen or to the seat of the hernia, followed by a sense of weak-
ness or of something having given way. An actual hernial protrusion, how-
ever, is usually not recognizable for some time, perhaps for weeks or months.
The patient will sutler meanwhile from a sense of fullness or weakness at the
seat of the hernia, accompanied by dull, dragging pain, increased by prolonged
standing or straining, and caused to diminish or disappear when the patient
lies down. In addition there may be intestinal disturbances, constipation, occa-
sional nausea, and vomiting. A good many of these patients soon discover
that the pain and discomfort is diminished by pressing over the site of the
hernia with the palm of the hand. If the hernia becomes of considerable size
and is not retained by a proper truss, the patients usually suffer from mechan-
ical interference with the peristaltic action of the intestine, from constipation,
sometimes from diarrhea, colicky pain, flatulence, dyspepsia, and other digestive
disturbances. Under these condition- they are apt to become mentally de-
pressed, to think much about tlu 1 movements of their bowels, and t" be disin-
clined for physical labor or exertion.

Clinical Varieties of Hernia. — The basis of the clinical classification of
hernia depends upon the contents of the sac and the relations of these contents
to the sac itself. There may be distinguished : (1) Reducible; (-) irreducible;
(3) inflamed; (4) obstructed: (.">) strangulated hernia'.

1. Rkiuchu.k IIikma.- — This is the mosl common variety, and includes
all the hernia' in which the contents can be replaced into the abdominal cavity
by ordinary means, such as posture and manipulation. As already stated, the
earliest subjective symptom is pain, and the other symptoms will be such
as have already been mentioned in the preceding paragraph. It' the hernia
i- of th«' congenital variety, no pain may be associated with it- production.



266 HEKNIA

Objective Symptoms. — These depend largely upon the size of the hernia
and the contents of the sac. If the hernia happens to be of the ordinary ingui-
nal variety a tumor is only present when the patient stands up or coughs,
and such a tumor may be simply a feeling of fullness appreciable on palpation
in the inguinal canal. The tumor disappears spontaneously when the patient
lies down. When the hernia has emerged from the external abdominal ring,
and has passed into the scrotum or labium respectively, the physical signs will
vary, as already described, according to the contents of the sac. The impulse
on coughing and the gurgling sound when the intestine is reduced remain the
characteristic signs of enterocele. Large scrotal hernia^, even though not adher-
ent, cease to be spontaneously reducible. Often these patients may learn to
replace the hernia in the recumbent position quickly and skillfully. The diag-
nosis of the variety and special forms and the differential diagnosis are dis-
cussed in the section on Special Forms of Hernia.

2. Irreducible Herxia. — A hernia is irreducible when its contents cannot
be entirely replaced in the abdominal cavity, though the function and nutri-
tion of such contents remain practically normal. The sac itself is only reducible
in very recent hernia? ; in congenital hernia, never. The commonest cause of
irreducibility is the formation of adhesions between sac and contents, most
often omentum. Further, adhesions between the contents, intestine to intes-
tine or to omentum, such that the adherent mass is too large to pass through
the ring. Inflammatory thickening of omentum, as already indicated, is
a frequent cause. Further, when the sac is incomplete, so that the contents
form a part of the wall of the sac, hernia of the cecum, for example. Also,
when so large a portion of the abdominal contents have been habitually
carried outside the belly that the abdominal cavity is no longer large enough
to contain them. Irreducibility is most frequent in umbilical hernia, and is
more common in the femoral than in the inguinal form, though any form
may become irreducible. It occurs most often during middle life, and is com-
paratively rare among children. Xinety per cent of the cases contain omentum
Olacready). Berger found omental adhesions or changes responsible for
irreducibility in 318 out of 582 cases. The condition may be temporary or
permanent, though a hernia long irreducible may finally become reducible. In
congenital inguinal hernia of the cecum in children, the cecum, or in some
cases other coils are found adherent to the testis, and thus irreducible.

Symptoms. — If the hernia is small, and consists merely of omentum, no
subjective symptoms may occur. If large, dragging of the omentum upon the
colon may produce more or less pain, discomfort, and disturbances of the
functions of the bowel. Attacks of inflammation often occur in these cases.
If the intestine is also irreducible, the condition is more serious, colicky pain,
flatulence, and constipation are common. Obstruction or strangulation may
take place at any time. These conditions occur more often in hernias with a
small hernial ring than in those where the abdominal walls are relaxed and
flabby and the hernial orifice large. Irreducible hernia is a condition demand-



CLINICAL VARIETIES OF HERNIA 267

ing operation, much more often than the reducible form. This is true oi both
inguinal and femora] hernia?. Contraindications are, a very large hernia,
extreme old age, obesity, conditions contraindicating surgical operations in
eral. I Sec also Umbilical I [ernia. |

3. [nflamed Hernia.— A localized peritonitis of the sac and it- contents

may occur in any hernia, h is mosl com n in irreducible umbilical and

femora] hernia?. The causes are accidental injury, the undue pressure of a
truss, unduly prolonged or vriolenl efforts at reduction (taxis), obstruction or
strangulation of the bowel, or acute enteritis. The peritonitis is usually of
iIm- sero-fibrinous type. A considerable serous exudate may form in the her-
nial sac, and if the process ends in resolution new and tinner adhesions are
formed. (See also Obstruction ;m<l Strangulation.)

Symptoms. — The hernia increases in size, becomes tender, hot, and pain-
ful. If much fluid is thrown ou1 into the sac, fluctuation or semifluctuation
may be detected. If omentum alone i- present, it feels hard and knobby. There
is usually a slight rise of temperature, 100° to 100.5° F., some acceleration
of the pulse-rate. If bowed is in the sac, there is often nausea, vomiting,
and constipation. If omentum merely, the symptoms are apt to be less
severe, and to subside in a few days under rest and suitable local treatment
If the hernia contains intestine, and notably if it be large, the greatest
watchfulness is necessary, since obstruction and strangulation are likely to
occur. No cathartics should be given, only enemata to relieve obstructive
symptoms.

Tuberculosis in a hernial sac has been observed, nearly always as a part
of a tuberculous peritonitis within the belly.

Actual suppuration in a hernial sac, aside from strangulation, perforation
of the intestine from typhoid or tuberculous ulceration, is occasionally observed
from the spread of a localized or diffuse purulent peritonitis. Very rarely a
hernia containing omentum merely becomes inflamed, and suppurates without
any evident source of pyogenic germs. Appendicitis in a hernial sac has occa-
sionally been observed. A definite diagnosis is hardly possible before opera-
tion. The following symptoms might lead to a suspicion of the condition.
Sudden violent signs of inflammation in a right-sided inguinal hernia, which
had been irreducible, and might well be small in size, vomiting, abdominal pain,
and the rapid development of marked septic symptoms, without at first abso-
lute obstruction of the bowels. In strangulated hernia, obstructive symptoms
occur first; septic symptoms may appear later.

4. Obstructeu Hernia — [ncarcerateu Hernia. — Impaction of -olid
feces in a coil of intestine occupying a hernia, usually large gut, may lead to
obstruction, total or partial, without serious impairment of the nutrition of
the intestinal wall. The condition i^ mosl often seen in old people with umbil-
ical hernia' containing large intestine, or who have large inguinal hernia 1 con-
taining sigmoid or cecum. The causes are constipation, indiscretions in diet
(gluttony), and the neglecl >'( proper precautions to keep the bowels open.



268 HEKNIA

the condition being encouraged by the intestinal atony common in the elderly
and in all coils of gut long resident in a hernial sac.

Symptoms. — The symptoms of obstructed hernia are characterized by a
gradual onset. They are increased local discomfort and a sense of tension
in the hernia, constipation, loss of appetite, a coated tongue, a foul breath,
headache, sometimes nausea and occasional, not continuous, vomiting. Fever
is absent. To these may be added colicky pain not only in the hernia, but in
the abdomen. Locally the hernia will be found increased in size, but only moder-
ately tender. Impulse on coughing is usually preserved, notably near the neck
of the sac. It may be faint, or in the obese hard to detect. On palpation
the doughy or hard scybalous masses may be more or less distinctly palpable.
The tumor may be dull or flat on percussion or tympanitic in places, accord-
ing to the presence or absence of gas in the bowel. If unrelieved, the condition
slowly passes from bad to worse, the patients become weak from want of nour-
ishment, they vomit from time to time, and toward the end the vomit may
acquire a stercoraceous character, and they may die exhausted, from chronic
intestinal obstruction and autointoxication, at the end of several weeks. In
other cases strangulation may supervene ; this is exceptional. After death no
inflammatory lesion or serious impairment of nutrition may be found in the
obstructed bowel. The treatment consists of high enemata, massage of the
hernia and of the abdomen, washing out the stomach, but no purgatives until
the bowel has at least been partly emptied. If, as is unusual, the hernia was
reducible before the obstructive symptoms occurred, a careful and gentle eifort
may be made to empty and replace the hernia under a general anesthetic.
Symptoms pointing to strangulation demand operation. The diagnosis is
usually easy from the history of a large irreducible hernia, usually in an old
person, the constipation, and the gradual onset of the symptoms, together with
the physical signs, as described. The age of these patients and the character
of these hernia? makes operative interference a serious matter.

5. Strangulated Hernia. — The importance of strangulated hernia re-
lates" usually to the presence of bowel in the sac, rarely to omentum alone. A
hernia containing bowel is said to be strangulated when the lumen of the gut
is occluded while the circulation of blood is cut off. The hernia becomes irre-
ducible spontaneously, and gangrene of the bowel finally results.

Occurrence. — Strangulated hernia is rare during infancy, common during
middle life and old age. It occurs more often in small hernia? with a narrow
ring. More rarely in large hernia? with a large ring. More commonly in
ancient than in recent ruptures, although a hernia may become strangulated
at once as soon as it appears. It is more common in femoral than in inguinal
hernia; 9.02 per cent of the cases in femoral, 2.16 per cent in inguinal (Ber-
ger's statistics). Ancient umbilical hernia? with prolapsed omentum and intes-
tine and numerous adhesions often become strangulated.

Causes. — Muscular effort, lifting, coughing, straining, anything which
causes a sudden increase of abdominal pressure, may lead to strangulation.



CLINICAL VARIETIES OF HERNIA

Certain . diseases will therefore predispose to strangulation, constipation, a
chronic bronchitis, stricture of the urethra, prostatic hypertrophy, and occupa-
tions involving violenl muscular strains, especially Lifting efforts.

Mechanism.— Much time and ingenuity have been expended in attempting
to accounl \<<v the occurrence of strangulation. Probably the mechanism varies
much in differenl cases. The following factors have been considered important
by differenl observers in the production of strangulation: ( 1) Elasticity <»f
the ping < Richter). (2) Compression of the efferent by the distended afferent

porti if iIm' loop (Lossen). (3) Angulation of the distal end of the loop

al the margin of the ring (Scarpa). < l) Fecal impaction. (5) Torsion or
volvulus of the loop ( I )e Roubaix). (0) Valvular folding of the mucous
membrane (Roux). (7) Interposition of the mesentery between the limits
of the prolapsed loop, thus wedging the bowel more firmly against the borders
of the constricting ring (Lossen). By whatever mechanical means the impris-
onment and pressure upon the bowel is commenced, once started, the condition
tends to continue and to grow worse, producing marked interference with the
circulation of the bowel and of its mesentery; the mesentery becomes swollen,
and is pul upon the stretch by the violent peristaltic efforts of the intestine
to tree itself, and the disturbances of circulation may involve also the mes-
entery lying within the belly by obliteration of the lumen of its vessels by
traction. Volvulus of coils of bowel lying within the abdomen may also occur.
The pathological changes in the imprisoned loop are venous congestion, swell-
ing and edema, paralysis of the muscular wall of the gut, an increased secre-
tion of mucus in its lumen, hemorrhages into the wall of bowel and into its
interior; at the same time a serous exudate, varying in amount, takes place
into the sac from the bowel.

In large hernia 1 and also in cases where the strangulation takes place
rather slowly, the quantity of serum which exudes will be larger than in
small hernia', where complete strangulation occurs suddenly. This serum, at
first colorless or amber-colored, becomes later stained with blood pigment; may
contain flocculi of fibrin or small blood clots; later it becomes cloudy with
leucocytes, and after a variable time putrid; migration of bacteria takes place
from the interior of the bowel, usually after strangulation has existed for
twenty-four hours, sometimes earlier, sometimes later, depending upon the
rapidity with which the gut loses its vitality, and especially upon the loss of
the lining epithelium of the bowel and the presence of hemorrhages into the
intestinal wall. The bacteria found in the exudate are the various form- of
pyogenic cocci and the Bacillus eoli. Owing to the bactericidal properties of
serum, they sometimes possess at firsl but feeble vitality. The rapidity with
which the gut becomes actually gangrenous varies with the completeness oi
the strangulation. Tf the blond supply of the bowel is suddenly and completely
shut off gangrene may occur in a very few hours. If only gradually, it maj
be postponed in certain cases for days. The gangrene begins usually in the
mucous membrane and spreads to the other coats of the bowel. It may be



270 HEEXIA

localized in small patches here and there or diffuse. Rupture of the bowel
then takes place, and the hernial sac is filled with a putrid fluid accumula-
tion, a mixture of the serous exudate and of intestinal contents, gas, and of
bacteria. The physical changes in the appearance of the intestine are as fol-
lows: As soon as the circulation is seriously interfered with the bowel becomes
dark red, and then purple or mahogany in color, the walls of the intestine are
edematous. The color changes from bluish-red to greenish- or grayish-black
when gangrene is complete. The peritoneum loses its smooth and glistening
appearance and becomes rough and dull. TJsually at the neck of the sac there
is a ringlike groove where the constriction has occurred. Often this area under-
goes gangrene very early, and appears as a gray or grayish-black furrow, and
here the gangrene takes place from without inward. The gangrenous intestine,
if not yet ruptured, is completely paralyzed and distended with gas. A local
peritonitis is early developed of the intestinal loop and the walls of the sac.
This may spread to the interior of the belly and produce a diffuse septic peri-
tonitis or be shut off by adhesions. As stated, the circulatory disturbances are
not always confined to the constricted loop of bowel.

Interference with the mesenteric circulation may lead also to gangrene
of portions of the intestine within the abdominal cavity, and the extent will
vary between a limited area of the wall of the gut at some particular point
and a number of feet. It is quite important for the surgeon to be able to
recognize upon opening the hernial sac whether the gut can properly be re-
turned to the abdominal cavity or not. _ If the fluid contained in the sac is
clear and has no bad odor it is a favorable sign. If, on the other hand, it is
putrid or contains gas or intestinal contents, it indicates very positively that
the condition of the gut will not permit its replacement in the abdominal
cavity. If the peritoneal surface of the gut is smooth and bright, although it
may be dark red or purple in color, it is a favorable sign. If the bowel is
distinctly flabby and paralyzed, entirely wanting in contractility, and if, after
the division of the constricting band, no return of circulation in the prolapsed
loop occurs after it has been washed with hot salt solution and covered with
a hot wet towel for a few moments, it indicates that its vitality is destroyed.
In cases of doubt, however, the bowel may be left in the wound, and observed
again after an interval of twelve to twenty-four hours. It is to be borne in
mind that extensive thrombosis of the vessels of the mesentery may spread
within the abdomen, and thus cause gangrene of the bowel and diffuse septic
peritonitis. Peritonitis may also occur from distention ulceration (Kocher)
of the intra-abdominal intestine leading to the hernial orifice. The afferent
loop becomes enormously distended from accumulated contents, gas and feces.
Its circulation interfered with by such distention, ulceration, and perforation
may follow with fatal results in spite of a successful operation upon the hernia
itself. When the gut in the hernial sac becomes gangrenous and ruptures, the
mixture of its putrid contents, bacteria-bearing feces and gas, is poured into
the sac, and soon sets up a rapidly spreading septic phlegmon or fecal abscess



CLINICAL VARIETIES OF HERNIA 27]

(assuming thai the patienl lias survived 30 long I. Burrowing of such an ab
in all directions occurs with greal rapidity. The -l.m is extensively under
mined and often perforated al several points with the discharge "l foul pus,
gas, and fecal matter. In this manner il is possible for relief of the obstruc-
tion to "•■cur, with the formation of an artificial anus. In partial hernias
(Riehter's) 9uch an evenl may form an artificial nuns or fecal fistula, and
spontaneous cure is possible, as it i< in very rare cases when the entire caliber
of the gul is involved. ( Sec my case, vol. i. page ~~>~. ) Usually these patients
<lie nt' septicemia speedily, <>r after prolonged suppuration.

General Symptoms of Strangulated Hernia.— Although the symptoms of
strangulated hernia vary much in differenl cases, depending upon causes to be dis-
cussed later, yel in the average case they are fairly typical. They may be divided
into general and local signs and symptoms. The general symptoms are, broadly
speaking, the symptoms of acute intestinal obstruction from strangulation;
whereas, as has already been pointed out, the symptoms of an obstructed hernia
resemble those rather of chronic intestinal obstruction. Very often the patienl
will be able to refer the occurrence of strangulation to some special cause —
a violent attack of coughing, an effort to lift a heavy weight, an attack of
vomiting, straining a1 stool, or some other similar incident. The patient
during one of these physical efforts will be conscious of an increase in size
in the hernial tumor, if such be present, and of severe pain of an aching character
felt at the site of the hernia: in addition to which there will be severe colicky
pain, referred to the umbilicus or to the lower part of the abdomen in general.
The patienl will speedily vomit the contents of his stomach. The vomiting is
repeated at frequent intervals, and resembles thai from acute intestinal obstruc-
tion by strangulation from internal causes — that is to say, it soon becomes bile-
stained, is large in quantity, and during- the later stages of the condition con-
sists of the contents of the intestine above the obstruction and assumes a fecal
character. This material is regurgitated suddenly, without warning, in large
quantities and without much apparent effort; it is the typical vomiting of
intestinal obstruction. Tt may be accompanied by hiccough. It may be absenl
in partial hernia, and may cease when the bowel is gangrenous.

Soon after the onset of strangulation very active peristalsis occurs. The
patienl ha- a desire to move his bowels, and a movement occur-, emptying the
intestine below the strangulated point. Tn most cases, after this, neither gas
nor feces pass per rectum, though the patient may have an intense desire to
defecate, and usually makes repeated attempts to do so. In partial hernia there
may be diarrhea, and in rare cases of complete hernia, high up in the small
intestine, a diarrhea may occur, due to a profuse secretion from the mucous
membrane of the bowel below the obstruction; this was designated by Mal-
gaigne as the cholera of strangulated hernia (cholera herniaire). The degree
of abdominal distention varies greatly, according to the site of the hernia.
If it be high up in the small intestine there will be little or no distention, if
low down in the large intestine, the distention will be very marked indeed:



272 HEKKTA

the development of peritonitis will be followed by general tympanites. A
distinct evidence of increased peristalsis is sometimes observable by aus-
cultation and palpation of the abdomen in the earlier stages of the disease ;
later, when the intestine is paralyzed or peritonitis has developed, it is
abolished.

General Condition. — In many cases the general condition is profoundly
affected at once. The patient falls almost immediately into a state of collapse.
In other cases the general condition will remain good for a number of hours.
When symptoms of collapse come on, the pulse, formerly strong and full,
becomes rapid, thready, and compressible. The temperature is usually subnor-
mal, the extremities become cold and moist, the nose looks sharp and pinched,
the facial expression is anxious, the mucous membranes assume a bluish, livid
color, and this condition of collapse may go on, accompanied by the vomiting
and abdominal pain, to a fatal issue, without any other complication. The
duration of life in these cases, if not operated upon, varies from less than a
day to from five to seven days. If peritonitis is developed the face may become
flushed, the temperature may be moderately elevated, or not at all ; there will
be general tympanites. In some of the cases the patient will feel relatively
well, although actually dying, and this condition of hopefulness may endure
until the last. In case the gut ruptures into the hernial sac, the patient may