IX.

STRANGULATED FEMORAL HERNIA.

BY J. BEAKLEY, M.D., NEW YORK.

SOME months since I was requested, by a medical friend in the country, to visit with him a female patient who was laboring under crural hernia. The patient stated that she had never worn a truss, although the rupture had existed for more than four years; that for the last year she had not been able entirely to reduce it, but that it had never before been strangulated. The fact that the invalid never had worn a truss is worthy of attention, inasmuch as it shows that firm adhesion of the neck to the intestine may take place independent of the pressure of the pad upon this part.

On examination, I found a firm elastic tumor, about the size of a small hickory-nut, in the right groin; the tumor was not discolored, and but slightly painful, although there was considerable pain and tension of the abdomen. She was very feeble, and constantly vomited a dark-yellow, offensive fluid; her pulse was small and quick. The strangulation had existed about eighteen hours, and, as her medical attendant had in vain tried taxis and other means likely to promote the reduction of the hernia, it was thought advisable at once to proceed to an operation.

On laying open the sac, the intestine was found much congested and inflamed, but its coats were otherwise uninjured. There were about two drachms of fluid in the sac, but no omen

tum; there were no adhesions between the body of the sac and the intestine; but, on introducing the finger toward the neck of the sac, and endeavoring to divide the stricture, I found that here the adhesions were so intimate and general between the sac and the intestine as to occasion great difficulty in introducing either the end of the finger-nail, or the point of the hernia. knife, so as to enable me to relieve the stricture. Indeed, it was only after a considerable time that I was able to effect this at the inner part of the neck of the sac, and thus relieve the stricture by dividing Gimbernat's ligament.

Had this been the first instance in which I had operated for hernia, I might have thought that the difficulty encountered was chiefly owing to my own inexperience; but, as I had already repeatedly performed this operation successfully, I flattered myself that this was not entirely the cause, but that a case might occur in which the adhesions were so general and intimate, and the stricture so great, as quite to prevent it from being relieved in the usual way.

It is obvious that in such cases, even were it practicable, division of the ring from without inwards would be unavailing as the stricture would probably exist at the neck of the sac. It becomes, indeed, a highly important question how the surgeon is to act in a case of this kind, all the distressing symptoms of strangulation continuing, and the danger of a fatal termination becoming every moment more imminent. Should the intestine, upon opening the sac, be found to be in a state of gangrene, or bordering upon such a state, the operator would not hesitate about laying open the bowel at once, and giving exit to its accumulated contents; but, finding the intestine healthy otherwise than as affected by congestion or inflammation, the young practitioner would, I think, hesitate about such a mode of procedure, notwithstanding his inability to relieve the stricture in the usual manner.

It appears, to my judgment, that the conduct of the surgeon

in the case under consideration ought to be guided by the nature of the immediate cause of the danger resulting from the stricture. From what writers, who have treated of this subject, have stated, I think there can remain little doubt that the more urgent danger arises from the complete obstruction to the passage of the intestinal contents, and their accumulation above the strictured portion of the intestine.

Mr. Travers, in his excellent work on Injuries of the Intestines, has particularly treated of this cause of danger; so also has Teal, in his work on Hernia: but I am not aware that, in most of the other excellent works we have on this subject, the emergency to which I refer has been considered.

If, now, the cause of danger and of death be the obstruction. to the passage of fæcal matter, it is evident that the only chance of averting this would be to lay open at once the intestine, although unimpaired in its texture otherwise than by congestion or inflammation; and, if this did not allow sufficient escape to the accumulated contents of the bowels, to divide the intestine and stricture together, and thus allow the patient the chance of life, recovering with an artificial anus.

In performing the operation for femoral hernia in a female, Arnaud, as reported in his Mémoires de Chirurgie, found the intestines so adherent to the neck of the sac, that he could not, at any point, introduce the director between this and the gut. In vain did he introduce his crotchet under the crural arch; he found it quite impossible to relieve the stricture and replace the intestine. Finding every other means futile, Arnaud resolved upon laying open the intestine, and so dividing it, and, at the same time, the neck of the sac and the crural ring. This was done, and the patient recovered with an artificial anus.

If the adhesions be loose and spongy, they must be broken down, if possible, by the introduction of the finger-nail or the handle of the scalpel; if, however, these means fail, the gut and the neck of the sac must both be laid open.

§ V.-5