Cases of strangulated hernia / [James Spence].

  • Spence, James, 1812-1882.
Date:
[between 1850 and 1859?]
Catalogue details

Licence: Public Domain Mark

Credit: Cases of strangulated hernia / [James Spence]. Source: Wellcome Collection.

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    along the chord, I was sure I felt a small swelling veiy deep, and too tense to be merely a part of the sac, and, therefore, after ex¬ plaining the necessity of giving the patient a chance of reliefj I operated, and as it proved, the state of matters justified my decision. In a younger person, there would have been less room for hesitation, because in such a case the mere incision, even supposing no hernia had been found, would not have been dangerous. In the case of Mrs W., though there was doubt as to the nature of the hard small swelling, still I felt no hesitation as to the practice to be pursued, for the existence of a tumour near the ordinary position of hernia, combined with the symptoms present in her case, is a sufficient warrant in my view, to cut down upon, and expose it. For w^e not unfrequently find small femoral hernise lying under glands, adherent to the surface of the sac, and even if no hernia be found, no great harm is done, or rather the real nature of the case is rendered clearer by the process of exclusion ; and the practitioner may use more powerful remedies than he could venture to do, so long as there was any probability of strangulated hernia being present. On the contrary, if the surgeon for fear of not finding a hernia, delays too long in such a case, then he most certainly puts his patient’s life in great jeopardy. Besides the difficulties of diagnosis, there is another point of interest in Mr C-’s case, the peculiar cause of strangulation of the small knuckle of bowel. When the great mass of the hernial contents were reduced by taxis, What prevented the return of this small portion ? Before operating, I thought it might depend on a double constriction in the sac, similar to that in the case of P- B-, recorded in the series of hernia cases, in this Journal for August 1845. But on opening the sac, the true cause was explained by the presence of a band of lymph, constricting the loop of bowel, in fact, an internal strangulation within the hernial sac, keeping the constricted portion distended, leading to its further strangulation by the neck of the sac at the deep ring, and so preventing reduction. The occurrence of such cases has sometimes been argued against the extra- peritoneal operation for hernia, as it has been said that we cannot be certain in any case that such an internal constriction may not be present. But if we pay attention to the rule to make sure of being able to return the contents of the sac without forcible pres¬ sure, and take care not to push the sac and its contents back en masse, we may feel satisfied there is no such constriction. For although in this case not only all constriction external to the sac was divided, but even the neck of the sac itself, the knuckle of bowel still remained tense, and could only have been reduced by forcible pres¬ sure, if at all, and therefore I believe that the objection is ground¬ less, inasmuch as division of the textures external to the sac would not permit of reduction, and thus the surgeon would be necessitated to open the sac, and so recognise the true nature of the case.