HERNI)E Abdominal Hernia in the Horse Abdominal hernia is of two kinds: (1) External abdominal hernia.
(2) Internal abdominal hernia.
External Abdominal Hernia Definition. - A hernia is the protrusion of an abdominal organ through an accidental or physiological opening in the abdominal wall to form a swelling beneath the skin, which remains intact.
(2) The hernial swelling.
Its size, as a rule, varies from that which will admit the insertion of one finger to that admit ting four fingers of the extended hand, but in exceptional cases it may be much larger.
Its shape may be round, oval, slit-like, or irregular. It may be a simple orifice, or in the form of a passage with an upper and a lower opening as in inguinal hernia.
(2) The Hernial Swelling. The hernial swell ing varies in size from a grape to a man's head, or rarely, something much larger. Its shape may be more or less hemispherical, cylindrical, or cone-shaped. It comprises (1) the hernial sac, and (2) the hernial contents.
(1) The hernial sac encloses the hernial con tents and is composed from without inwards of skin, perhaps a few muscular fibres, fibrous tissue, and parietal peritoneum, but the last mentioned structure may be absent in ventral hernia owing to its being ruptured by the violence which caused solution of continuity in the abdominal wall. Some authorities confine ii Pie. 186. Parts of a hernia.
(a) edge of hernial opening, (b) and (f), parietal peritoneum (c) muscle; (d) hernial contents; (e) bowel; (0 fibrous tissue between peritoneum and skin; (h) hernial sac.
the term"sac"to this peritoneal layer of the hernial coverings, and speak of the others as accessory envelopes. There may be a large amount of thickening in the fibrous portion of the sac, particularly in an old hernia, and in the latter case it may contain calcareous material. This fibrous thickening may give the impression that there is adhesion between the sac and its contents. The sac has a neck and a body, the former being the part next the ring and the latter the remainder of the structure. The serous sac has an exquisitely smooth inner surface which facilitates the escape of abdominal organs from the peritoneal cavity. It is thrown into folds at its neck, and these may in excep tional cases become united by inflammatory adhesions, and tend to or actually close the entrance to the sac by the process of cicatriza tion.
(2) The hernial contents are usually a loop of bowel with its ingesta and attached mesentery (enterocele), or omentum (epiplocele), or both (entero-epiplocele), less frequently the stomach (gastrocele) or bladder (ve,sicocele), and rarely some other abdominal organ (spleen, liver). In addition there is often present some serous fluid (hernial fluid). In subjects like the ass and mule, in which there is much sub-peri toneal fat, and in which the hernia is small, the contents may be composed entirely of sub serous adipose tissue which prevents protrusion of the peritoneum and abdominal viscera through the hernial orifice.
Varieties of Hernim.Herniae may be classi fied according to their situation, viz. umbilical hernia (omphalocele, exomphalos), inguinal hernia (bubonocele), scrotal hernia (oscheocele), ventral hernia, femoral hernia, and perineal hernia; or according to the nature of the hernial contents, viz. enterocele, etc.; or accord ing to the condition of the contents as follows: (a) Reducible hernia, in which the contents can be readily pushed back into the abdominal cavity through the hernial opening.
(b) Irreducible hernia, in which they cannot be returned to the peritoneal cavity.
Irreducible hernia comprises (1) Incarcerated, (2) Strangulated, and (3) Adherent hernia.
(1) Incarcerated hernia, where the contents are too large to pass through the hernial ring into the abdomen.
(2) Strangulated hernia, where the contents are not only incarcerated but are so compressed by the hernial orifice or by the constricted neck of the sac, or by both, that their circulation is arrested and the `them of the bowel is obstructed, causing them to undergo death or gangrene within twenty-four hours if relief is not forthcoming, micro-organisms passing from the interior of the viscera through its weakened or mortified walls into the peritoneal cavity, and giving rise to a fatal peritoneal septicaemia. The cause of the strangulation is a sudden increase of the intestinal contents in the hernia, producing obliteration of the lumen of the efferent end of the herniated loop of bowel by pressing its walls together against the edge of the ring. Eventually the mutual pressure of the two parts of the loop effectually closes its entrance and its exit, causing faecal stasis and arrest of the circulation in the part. The double dovetailing of the mesentery, attached to the affected part of the bowel between the abdomen and the hernia, acts as a wedge in the opening, and shares in the process of strangulation. The intestinal mucous membrane at the constricted part acts like a valve gliding on the other coats of the organ, and tending further to occlude the passage and imprison the contents of the herni ated portion of bowel. In the early stages of strangulation there is venous congestion of the contents owing to the blood continuing to flow in through the arteries for some time after the veins have become occluded, the constriction affecting the latter first on account of their thin walls. There may also be small haemorrhages due to the rupture of congested capillaries. There is a variable quantity of serous fluid in the sac resulting from the venous engorge ment.
The bowel may be much altered in colour, appearing blackish from cyanosis and ecchy mosis, and yet retain sufficient vitality to regain its normal condition, but on the other hand the alteration may not appear serious, yet when the piece of bowel is returned to the abdomen it undergoes gangrene and causes death from peritonitis. When strangulation has been in existence for some time the signs of death in the strangulated bowel are unmistakable; it becomes blackish, greyish, or yellowish hi colour, and may be ulcerated or perforated.
In entero - epiplocele the omentum, swollen and hyperaemic, supports part of the pressure, relieving to some extent the bowel, in which the lesion is less marked and slower in forming than in a case of enterocele. When the strangula tion is not very acute, adhesions form between the contents and the sac, especially at its neck, and may be sufficient, in exceptional cases, to shut off the peritoneal cavity while perforation of the sac takes place externally. Therepay be only a portion of a loop of intestine strangulated, one wall only of the bowel being caught or pinched in the hernial ring.
(3) Adherent hernia, in which the contents are united by inflammatory adhesions to the lining of the sac. When recent, the adhesions are fibrinous and easily ruptured, but when of long standing they are fibrous and permanent. They may be in the form of bands or plaques. They prevent complete reduction of the hernia, and may constrict the bowel, giving rise to strangulation.
Etiology. Hernia may be congenital, as is often the case with umbilical and inguinal herniae. The etiology of acquired hernia com prises (1) Predisposing causes, and (2) Exciting causes.
(1) Predisposing causes include heredity and conditions which lead to the formation of weak points in the abdominal wall, such as imperfect closure of the umbilicus, deep wounds, contusions, or abscesses, or which bring about increased intra-abdominal pressure, such as straining from diarrhoea or constipation or parturition, fits of coughing, and tympany.
(2) Exciting Causes. The exciting causes comprise increased intra-abdominal pressure, which tends to force the viscera through the weak spots in the wall of the abdomen, and violent impact against a blunt body, which causes rupture of the rigid muscles whilst the skin, by virtue of its mobility and elasticity, suffers merely from contusion.
Symptoms. The symptoms are (1) Physical, and (2) Functional.
(1) Physical Symptoms. The physical symp toms are due to the presence of the hernial swelling, which varies in shape and size as already described, and presents features which differ according to the nature of the hernia. It is elastic to the feel in the case of enterocele, and doughy in that of epiplocele; manipulation of the former may produce a gurgling noise and detect the vermicular movement in the bowel. If the herniated portion of intestine is distended with gas it will be tympanitic on percussion, and if it contains a quantity of fluid it will fluctuate on palpation. It may be tympanitic towards the neck of the sac while fluid occupies its lower part. In entero-epiplocele there is a combina tion of the foregoing characters. In reducible hernia the swelling can be diminished or made to disappear by pushing the contents into the abdomen, when the edges of the ring can be readily felt by inserting two or more fingers through the opening. During manual reduc tion of the hernia, bowel slips back suddenly into the abdominal cavity, accompanied as a rule by a gurgling sound, while the omentum is more gradual in its disappearance and may transmit a slight sense of crepitation to the hand due to friction against the walls of the sac. When both are present the former is reduced first. If the patient makes a sudden effort or is made to cough, the swelling can be seen and felt increasing in size, a sense of expansion or repulsion being perceived by the hand when applied to the enlargement. When adhesions are present it is possible to diminish the swelling by pushing it through the hernial ring, but the sac cannot be detected from the contents.
Incarcerated hernia gives rise to similar symptoms, except that it cannot be reduced and the ring cannot be easily felt .
Strangulation is usually indicated by well marked symptoms. The swelling increases in size, becomes hard and tense, painful and irre ducible, and fails to expand or convey an im pulse to the hand when the patient is compelled to cough. As a rule the hernia has been in existence as an ordinary rupture for some time before becoming strangulated, but sometimes it is strangulated at the time of its production and is then spoken of as acute hernia. After gan grene has set in, the inflammatory symptoms disappear and the hernia becomes cold and insensitive.
(2) Functional Symptoms. In an ordinary reducible hernia the functional disturbance is -practically nil. There may be some evidence of indigestion, and an occasional slight attack of colic. Incarcerated hernia is more likely to be accompanied by these symptoms. Strangula tion is usually associated with severe and con tinuous abdominal pain, a febrile reaction, and symptoms of obstruction of the bowel. The animal may lie on his back to try and obtain relief from the pain.
When gangrene supervenes the pain subsides, and the patient becomes dull and listless, with a subnormal temperature, an almost imperceptible frequent pulse and cold extremities, being in fact moribund.
Deceptive cases are occasionally met with where the local inflammatory phenomena are not very severe and the symptoms of abdominal pain are not very marked, yet gangrene and death supervene if intervention is too long delayed.
Diagnosis. The diagnostic features of re ducible hernia are its reducibility, the presence of the hernial ring, and the expansion of the swelling against the hand during coughing. Diagnosis is more hesitating with incarcerated hernia, but it is generally arrived at after care ful examination. Conditions with which it may be confounded are abscess, tumour, hematoma, and aneurism, but any person familiar with these lesions is not likely to confuse them with hernia. In strangulation the characteristic symptoms are the local phenomena and the general disturbance. When doubt exists it may be removed by making an exploratory puncture with a fine trocar and cannula or an exploratory needle, which will help to reveal the nature of the swelling. Rectal examination may also be of assistance.
Prognosis. Congenital hernia (inguinal, um bilical) may disappear spontaneously within one year after birth, the opening closing as the muscles develop. Its cure is favoured by the bowel becoming distended by hard food and by nutritious diet, and is therefore much more likely to occur in colts when they are housed and hand-fed during the winter. If it does not supervene within this period the hernia is likely to persist and may increase in size. As time goes on the sac may become greatly thickened by an increased amount of fibrous tissue. The contents are always more or less exposed to external injury, especially in a large hernia, on account of the prominence of the swelling and the inadequate protection afforded by the hernial sac. A big hernia may interfere with a horse's usefulness. A horse with a hernia may work all his life without suffering inconvenience, but there is always the danger of strangulation taking place, and from this point of view recent hernia is more serious than old hernia, and irreducible is more dangerous than reducible hernia. When the hernial swelling is large compared with the size of the hernial ring, strangulation is more likely to supervene. It is more apt to occur in horses doing hard work than in those doing light work, and the small intestine is more easily strangulated than colon or omentum. Strangulation of the intestine is obviously a very dangerous condition.
Treatment consists in adopting measures which will have the effect of returning the hernial contents into the abdomen and causing cica trization in and consequent closure of the neck of the sac, and therefore obliteration of the hernial orifice. Its details will be given in connection with the different forms of hernia.
Umbilical Hernia Synonyms. Omphalocele, exomphalos.
Etiology. Umbilical hernia may be con genital or acquired during the first few weeks after birth as the result of straining from diarrhoea or constipation, or from the exertion of playing or gambolling, or making some effort involving violent contraction of the abdominal muscles.
Viscera appearing in a dilatation of the cord without a covering of skin is a prolapse of the bowel and must be distinguished from hernia.
The hernial contents may be either bowel (ccum or colon) or omentum, or both.
The hernial sac is composed of skin, fibrous tissue, and parietal peritoneum. The fibrous tissue is in the form of a fibrous membrane which is often very much thickened at the base of the sac.
Symptoms. The symptoms are those of a hernia at the umbilicus, the swelling and hernial ring varying in size and shape as stated.
Prognosis. Incarceration or strangulation seldom occurs, probably on account of the nature of the contents. It frequently dis appears spontaneously. It may disappear with in the first six or twelve months of age as the result of the bowel becoming distended with solid food and the abdominal muscles develop ing and filling up the opening in the abdomen as the animal grows. Adhesion between the sac and contents is rare.
Treatment. When the animal is under one year old and the hernia is reducible and not threatened with strangulation, nature may be trusted to effect a cure of her own accord or she may be assisted by the use of a truss, blister, or caustic agents, which are of little or no avail in older animals. A truss is a pad which presses against the hernial opening and retains the hernial contents in the abdomen, thereby favouring closure of the entrance to the hernial sac. It is kept in position by a roller. It requires to fit accurately and to be well adjusted, otherwise it may become dis placed or cause chafing or even necrosis of the skin. The patient may resent wearing it, and fret and fail to thrive from the irritation caused by it. When of a good pattern and properly applied it is undoubtedly a useful contrivance, although it may often obtain credit for effecting a cure which might have occurred without its aid. A blister applied to the hernial sac will cause a certain amount of inflammatory swelling, which will tend to push the contents of the hernia into the abdomen and give rise to sub sequent fibrous tissue formation and cicatricial contraction, which will help to reduce the size of the sac and that of the hernial opening. The application of a caustic will cause an eschar and the same results as a blister, but to a more marked degree. Sulphuric acid 1 part to 3 parts of water, applied daily for five to eight days, has often been used with apparently good effect. Pure nitric or sulphuric acid applied in lines with a glass rod not more than twice is also of service. The hair should be clipped before applying these dressings. The action of the caustic must be carefully watched, for if used too often or rubbed in too much a deep slough may form and be followed by prolapse of the bowel. Chromic acid, bichromate of potash, or the actual cautery may also be used.
Bandaging and blistering combined is a method which, though more effective than either alone, is apt to cause chafing and great irritation. These irritant and caustic topics frequently fail to have the desired result and may, when repeatedly employed, cause great thickening of the sac, blemishing of the skin, and inflammatory adhesions between the sac and the contents, thus making operative inter vention more difficult and dangerous.
Subcutaneous injection of one to two ounces of a 15 per cent solution of common salt is another form of treatment with results similar to those of the agents just mentioned, but it has been known to cause severe sloughing. The injection of a few drops of a 10 per cent solution of zinc chloride has, according to a French authority, Launelongue, given remarkably good results in the treatment of chronic hernia in man. All the methods of treatment mentioned above are of doubtful benefit. If an almost certain cure is required it is better to proceed as in the treatment of older animals and adopt one of the following methods: (1) Ligation of the Hernial Sac. Clip the hair from round the neck of the sac before casting the animal. Control him in the dorsal position by means of side lines, or hobbles and a back strap. Chloroform is not necessary but is an advantage in preventing struggling, which interferes with the reduction of the hernia. Prepare the site of the operation by shaving and washing with an antiseptic solution or by the application of tincture of iodine after dry shaving. Reduce the hernia; then draw up the empty sac as much as possible from the abdomen, transfix its neck cautiously, flush with the abdominal wall, with a couple of skewers or special strong pins or even horse-shoe nails inserted at right angles to each other, and turn down their points with a bone forceps. Apply a strong india-rubber ligature tightly round the neck of the sac between the pins and the abdominal wall. The skewers may be inserted after first putting on the ligature. To facilitate drawing up the sac from the abdomen sterilized pieces of cord may be passed through it, one at its anterior and the other its posterior end, and formed into loops to serve as handles, or a clam may be applied near its base for the same pur pose. A stout silk or whip cord or fishing-line ligature may be used instead of rubber, and must be applied very tightly, either end being wound round a short metal or wooden rod to afford a grip for this purpose. It has the dis advantage that after some time, when it has cut partly through the tissues, it loses its com pressive effects, so that it may be necessary to apply another ligature to produce the desired effect; as a rule, however, this is not necessary. If the sac be too big for a single ligature, pass a large needle furnished with the cord through the centre of the neck of the sac and cut it close to the needle, thus making two ligatures. Intercross the latter and ligate the sac in two sections. If necessary, three or more ligatures could be applied in a similar fashion. The im portant point is to' make sure that the hernia is completely reduced before applying the liga ture or passing the skewers or needle through the sac. The ligature, especially the elastic one, must not be put on excessively tightly for fear of causing too early sloughing of the sac. If reduction be difficult, taxis on the bowel per rectum may be practised,- and if its return is prevented by tympany or distension with fluid it may be tapped or aspirated. If adhesions are present the sac must be opened aseptically and the adhesions separated by the finger if recent, or by careful dissection if old, but in such cases the procedure for the radical opera tion is advisable.
Ligation can be performed in the standing position, but not so satisfactorily as in the re cumbent position. This is a very good method for hernia of moderate size, being almost always successful.
(2) Use of Clams. The procedure here is the same as in the last instance, only a clam is used instead of a ligature. It is applied very tightly to the neck of the sac, as close as possible to the abdominal wall and parallel to its long axis. In the case where the umbilical opening is very close to the sheath the clam may have to be placed crosswise to prevent its interfering with this structure, but this is seldom necessary and should be avoided as much as possible, as the clam is less secure in this position, being more likely to be caught by something or by the patient's foot or teeth and torn off along with the sac, thus leading to eventration of the bowels. Pins or horse-shoe nails may be in serted transversely beneath the clam to prevent its slipping, or it may be secured by a few sutures passed through the sac above and below the clam and tied round the latter, or it may be fixed to a surcingle applied round the body. The clam may be made of wood or aluminium or iron, the first two having the advantage of being light. Unless the wooden clam is stout in its transverse diameter and provided with narrow opposing surfaces or edges it has not the same compressive effects as one made of metal. The edges of the metal clam are serrated to give them a grip on the skin. There are various patterns of clam: a common form is that whose two portions are brought together by a screw at either end; another one has a screw at one end and a hinge at the other. It cannot be fitted so evenly as the first one. Mr. Allen, of Dublin, has invented a metal clam whose two parts are kept in close opposition by means of a spring. Wooden clams may be fixed by means of cord at either end, or preferably by thumbscrews, which ensure more even and constant pressure. Desmesse and Degive, of Belgium, advise the use of two wooden clams for large herniae, one applied above the other, the function of the lower one being to prevent the upper one slipping.
In the case of a clam with screws it is advis able to turn the latter occasionally to maintain the pressure of the instrument on the sac as it cuts through the tissues, but care must be taken not to overdo this lest separation should take place too soon before cicatrization or closure of the opening is complete. Aluminium clams are not very reliable, being easily broken.
This is also an excellent method of treatment and is more easily carried out than that of ligation.
After-treatment. After operation the animal may be put in a loose-box or, if the season permit, on grass. He should be kept under observation lest he try to interfere with the clam. The sac and its vicinity should be dressed with an antiseptic once daily until the sac, along with the ligature or clam, falls off. This precaution is often omitted without the patient suffering any ill-effects. Laxative diet is in dicated, and bulky food should be restricted as it distends the abdomen and may over stretch the recent and comparatively weak cicatrix and lead to a recurrence of the condi tion. For the same reason violent exertion should be prohibited for months afterwards, until the scar tissue becomes strong, more particularly if the hernial ring has been large.
Subsequent Phenomena. Whether the clam or ligature be employed the subsequent pheno mena are the same. The animal may evince slight colic occasionally for a few hours after the operation, but as a rule he seems uncon cerned. On the following day inflammatory symptoms appear around the umbilicus, which becomes the seat of a hot oedematous swelling, and the sac becomes cold and purplish. There may be some inappetence and a rise of tem perature, but otherwise the patient is normal. Towards the fourth day the sac is dead. On about the twelfth or fifteenth day the ligature or clam and the sac fall, leaving a more or less extensive wound and considerable oedema, which gradually disappears. A depression is observ able in the position of the umbilicus, but at the end of three or four weeks the wound is com pletely healed and the umbilical opening is totally obliterated.
Complications. These methods have seldom any untoward result, but cases are recorded now and again where the sac and clam came off, or were torn off too soon, and prolapse of the bowel followed. Recurrence of the hernia may take place within one year after operation, but it is very uncommon and rarely super venes at a later period.
Suture of the Hernial Sac. Having reduced the hernia, grasp the sac with the fingers and thumb as close to the abdominal wall as possible and, inserting the needle immediately below the thumb, pass a series of interrupted stout Halsted silk sutures across the neck of the sac about half an inch apart. This brings about adhesion by cicatrization between the surfaces in contact and consequent closure of the hernial orifice. The empty sac may afterwards undergo atrophy and become obliterated or persist as a swelling of variable size, which may be excised when the hernial ring is permanently occluded, the resulting wound being sutured. The advantage of this method is that it is not followed by sloughing of the sac and the consequent risk of prolapse of the bowels as in the case of the use of the clam or ligature when separation takes place too soon. An objection to this procedure is that infection may possibly spread along the sutures from the skin into the abdominal cavity and cause peritonitis, but experience has shown that this complication is rare. Should it be necessary to open the sac, or should the hernial orifice be unusually large, proceed in a similar fashion, including the abdominal wall in the sutures, the fingers of the left hand being kept in the abdomen to guide the needle clear of the viscera when inserting the sutures. In this case it is essential to keep an antiseptic compress in contact with the wound for five or six days until union has occurred in the peritoneal part of the wound.
(3) Radical Operation. The radical operation is indicated in those cases where the sac has to be opened to relieve strangulation or to separate adhesions, or where one of the above methods has failed, or when the hernia is abnor mally large. Performed with proper aseptic and antiseptic precautions it is without danger. Keep the animal on laxative concentrated diet for a couple of days before operation and have him fasting on the morning of same. During the preparatory stage it is advisable to have the hair clipped from the hernial sac and its immediate vicinity and the region well washed, first with soap and water, and afterwards with ether and an antiseptic lotion. Cast and anwsthetize the patient and fix him in the dorsal position with the hocks well flexed and separated. Apply cloths wrung out of an antiseptic round the feet to prevent dust falling from them into the wound. Shave and wash with ether and antiseptic the site of operation, or apply tincture of iodine to it after dry shaving. Damp the hind limbs and surrounding parts with an antiseptic to prevent dust contaminating the field of operation. Have your hands, instruments, and materials sterilized and, every thing being ready, make an incision through the skin and fibrous covering of the sac over its centre or at a point where there is no adhesion parallel to the long axis of the body from the anterior to the posterior extremity of the swelling.
Isolate the delicate peritoneal lining of the sac from its other coats, reduce the hernia, seize this portion of the sac with an artery forceps, twist it into a cord, and apply a silk ligature round its neck as high up as possible, amputate the sac below the ligature, return the stump into the abdomen, freshen the edges of the hernial ring by scraping them with a knife or snipping them with scissors, and then bring them together with strong interrupted silk sutures. Shorten the skin to the required length and then suture it. Dress the external sutures with collodion and iodoform. When the patient rises, cover the wound with an anti septic pad and bandage, which, however, are not essential. Put the patient in a hygienic loose-box and give him the usual hospital diet. Healing by first intention may ensue but it is not the rule. When the wound suppurates, some or all of the buried sutures will require to be removed. If adhesions are present the peritoneum must be perforated to permit of their separation. If the latter is impossible the peritoneum may be cut round the adherent portion, which is then returned with the bowel.
If it be omentum that is adherent it may be excised after ligation if it is vascular.
If there be strangulation, lay open the peri toneal sac on a director to avoid wounding the viscus. Then introduce the index-finger into the neck of the sac beyond the stricture, pass a blunt-pointed straight knife along the dorsum of the finger flatwise, and, having cleared the stricture, turn the edge towards it and incise it sufficiently to permit of reduction of the contents. If there is not room for the finger in the stricture, insert a hernia-director instead or pass the knife alone cautiously through it on the flat with the edge directed away from the bowel.
During the operation of suturing, keep the fingers of the left hand in the abdomen to guide the needle clear of the abdominal organs. A very curved needle on a handle is the most suitable for suturing the ring.
Should the abdominal opening be large, a pad of lint laid on the abdominal organs beneath the wound will serve as a protection to them, and prevent their escape should the patient make an unexpected and violent struggle.
If the strangulated organs are undergoing necrosis the case may be considered hopeless. The indications here are to resect the necrotic portion of the bowel and unite the two ends by Lembert sutures or by an anastomosing button (Murphy's).
It is not worth while operating if the patient is in extremis, in a state of profound toxaemia and exhaustion.
(4) Degive's Method. In 1894 Degive intro duced a method of treatment which he said was superior to all other methods.
The procedure is as follows: Take the usual preliminary precautions for an abdominal opera tion as described above. Open the sac at about its centre to an extent sufficient to admit the first two fingers of the left hand. Pass a stout, slightly-curved needle, with a handle about ten inches long altogether, through the lips of the anterior half of the ring, not more than f of an inch from its edges, going through the skin, abdominal wall, and parietal peritoneum, guiding it clear of the abdominal viscera by means of the fingers in the abdomen. Pass another needle of the same kind in the same way through the posterior part of the ring. Apply a clam between the needles and abdominal wall, screw ing it as tightly as possible with the fingers and then screwing it a little more with pincers. When the clam has been secured withdraw the needles and insert in their stead pins or skewers as described, horse-shoe nails answering the purpose very well. This procedure has the effect of turning the edges of the hernial ring outwards and bringing the serous surfaces into close contact and maintaining them there until they become united. Owing to the way the clam is applied, a portion of the abdominal wall all round the ring is included in it and sloughs away along with the sac. Its place is taken by scar tissue, an imperfect substitute for the original specialized resistant structures. The
fact is that, except for the closure of the hernial opening, the wall of the abdomen is on that account weakened instead of strengthened by this operation. It predisposes to recurrence of a much larger hernia, through rupture of the extensive cicatrix. This unpleasant sequel is not, of course, the rule, but it has occurred sufficiently often, judging from reported cases, to make one hesitate about performing it, although one is tempted to do so—the procedure is so expeditious.
The author has had success with it in every case except one, in which the hernia recurred and was four times the size of the original one.
In all the recorded cases of failure the ring of the recurrent condition was much larger than that of the primary one. The recurrence usually appears some months after apparent cure has been accomplished.
Modifications of the Degive Method. (1) In a case where the sac must be opened, and it is considered undesirable to include the abdominal wall in the clam, the needles may be passed through the neck of the sac, inserting them at some distance from the edges of the ring to ensure the sac being well drawn out from the abdominal wall and the clam being applied as closely as possible to the latter between it and the needles.
(2) Proceed exactly as described in the Degive method until the needles are inserted, and then apply the clam (metal clam) just tight enough to keep the serous surfaces in contact. Insert a series of Halsted or mattress sutures through the ridge of tissues on this side of the clam close to the latter and about half an inch apart. Make the ridge of uniform height by cutting away the higher part of it, skin and fibrous tissue, and unite the cut edges of the skin with ordinary interrupted sutures. Dress the line of sutures with an antiseptic such as tincture of iodine or compound tincture of benzoin. Remove the clam, apply a large, moist, antiseptic compress over the seat of operation secured in position by a bandage round the body. Saturate the compress two or three times daily with a reliable antiseptic solution, such as hypochlorous acid or per chloride of mercury (1 in 1000) to prevent the possibility of infection extending along the sutures to the abdominal cavity.
Advantages of this Method. (a) The lips of the ring are accurately and securely maintained in contact. (b) There is no loss of abdominal wall, as sloughing does not occur. (c) The abdominal cavity is closed during the process of suturing, which can be rapidly performed with a straight needle. (d) There is no danger of prolapse of the bowel during or after the operation.
The author has performed this method with success in a case where the hernial opening was 7 by 6 inches.
(3) Isolate the peritoneal sac as in the radical method, ligature and remove it, and then pro ceed as in No. 2, inserting the needles through the skin and muscles only, not through the peritoneum.
There will be no danger in this case of infec tion spreading along the sutures to the peri toneal cavity, as they are outside it. This procedure is the safer operation, but the other one can be more quickly performed and is suitable for a ventral hernia in which the peritoneal sac may be absent. In either case the sutures should not be less than half an inch apart, otherwise the blood supply may prove insufficient and the sutures will then have the effect of ligatures or clams, causing sloughing.
Inguinal and Scrotal Herniae Inguinal hernia (bubonocele) and scrotal hernia (oscheocele) are practically the same thing, the latter being merely an extension of the former from the inguinal canal or region into the scrotum.
Etiology. It may be congenital or acquired soon after birth from causes mentioned for umbilical hernia. In adult animals it may be caused by the hind legs slipping outwards and backwards, thus dilating the inguinal canal; by heavy testicles, which tend to dilate the internal abdominal ring; and by too vigorous copulation, which has the same effect. The more or less erect position in this latter case also favours the condition. Dragging on the cord during castration, or the use of a heavy clam for this operation, may lead to its formation in the gelding. The sac of the hernia is formed by skin, dartos and tunica vaginalis. The contents may be intestine or omentum, or both.
Prognosis. When congenital it may dis appear spontaneously, as already stated. Occur ring suddenly in adult stallions it is usually strangulated. When large it may interfere with usefulness. It is more likely to become strangu lated than other forms of hernia.
Symptoms. The swelling may be invisible— that is, it may not appear outside the external abdominal ring or it may reach to the hocks. In chronic cases in stallions the testicle on the affected side may be atrophied.
The hernial contents are usually to the inside and in front of the spermatic cord or testicle, and are commonly situated at about the level of the epididymis, but in scrotal hernia they may be on the floor of the scrotum.
An incomplete inguinal hernia, not appearing outside the external abdominal ring, is difficult to detect. It may never be suspected until it becomes strangulated, and even then it may not be diagnosed. Rectal examination may reveal the bowel or omentum extending into the inguinal canal.
Recent inguinal hernia generally interferes with the gait, causing the hind limbs to be abducted and the toes to be dragged.
The testicle of the affected side may be drawn up and there may be slight colic. These symptoms may pass off or they may become intensified owing to strangulation taking place. The symptoms of strangulation have already been dealt with.
Diagnosis is made out from the character istic symptoms of a hernia in the inguinal or scrotal region. Distinguish it from sarcocele (a hard tumour of the testicle) and hydrocele (dropsy of the tunica vaginalis), which always occupies the floor of the scrotum and can be displaced from one part of it to the other. In the gelding, distinguish it from scirrhous cord and cyst of the end of the latter, following castration.
Treatment.(1) Reducible Inguinal Hernia. In foals and young animals closure of the inner abdominal ring may be attempted by causing inflammation of the spermatic cord and con sequent adhesion of it to the tunica vaginalis by vigorous rubbing of the skin at the level of the cord, or by tying a woollen cord above the scrotum and leaving it on for eight hours. Applying an irritant over the cord may have a similar effect.
Cure may occur, however, in these animals without any treatment, and the measures men tioned are not very practicable, neither are they much in vogue. Trusses are difficult to adjust in the inguinal region. In animals one year old and upwards the best treatment is to proceed as in the covered operation for castra tion, as follows: Cast and anaesthetize the patient and fix him in the dorsal position. Having taken the usual precautions, cut through the skin and dartos without incising the tunica vaginalis; enucleate the latter as high up as possible, give the cord one or more complete twists so as to close the sac inside the canal, and apply a clam round the cord outside the tunica vaginalis as close to the external abdominal ring as possible. When the clam is short it is more easily fitted high up, but then it becomes so embedded in the tissues that it is difficult to remove. A comparatively long wooden clam whose ends are outside the scrotal wound proves just as effective as the short metal one and has the advantage of being easily taken off. A ligature may be used instead of a clam, and is preferred by some operators on the ground that it can be applied further up on the cord, thereby more effectively closing the neck of the sac, but it is objectionable because it usually becomes septic, causing sup puration in the upper part of the wound, whence infection may spread to the peritoneum and cause peritonitis. The suppuration will con tinue until the ligature falls out or is taken away. To facilitate its removal, one end may be left protruding through the wound, but doing this favours sepsis by exposing the thread to contamination. When the patient is a stallion cut off the testicle about half an inch below the clam or ligature. The clam may be left on until it falls or is taken off in six or seven days or longer. If adhesions are present or suspected, the tunica vaginalis must be opened to separate them or to explore the interior of the sac.
(2) Strangulated Inguinal Hernia.It may be possible to reduce the hernia by scrotal taxis, that is, by manipulating the swelling and pressing upon it at the neck of the sac. This taxis may be mediate, that is, performed with out opening the sac, or immediate, that is, after opening it. Care must be taken not to use violence in pressing upon the bowel for fear of injuring it, especially as it is weakened from being strangulated. For this operation it is necessary to have the horse on his back, with the hind quarters raised, and under the influence of an anaesthetic. Taxis per rectum alone or associated with the foregoing may effect reduc tion. A little sterilized oil injected into the sac will act as a lubricant and facilitate the process. If the bowel is distended with gas or liquid, capillary puncture to permit of its escape may enable it to be returned. It is a mistake, however, to lose much time by these methods; it is better to perform the radical operation at once, for the longer it is postponed and the more the bowel has been bruised the less is the chance of success.
When it is done soon after the -occurrence of the hernia, before the patient is exhausted—not later than twelve hours afterwards—it is very likely to be successful.
Radical Operation. Prepare and take all precautions as usual. Anaesthetize the animal, and fix him on his back with the hind limbs well flexed at the hocks and drawn outwards. Incise the skin and dartos throughout the length of the swelling at its centre from before backwards and separate them from the tunica vaginalis up as far as the external inguinal ring. In some cases the tunica vaginalis is found ruptured. If not, puncture it at its posterior aspect without injuring its contents. Insert a director through this opening, pass it forward and incise the tunica vaginalis on it to the same extent as the skin wound. The hernial contents and testicle will now be exposed and appear more or less altered. If the loop of intestine is distended with gas or liquid its volume can be diminished by capillary puncture. Bathing it with 0.7 per cent warm sterile saline solution will have a good effect. Having decided that the contents are fit to be returned to the ab dominal cavity, pass the left index-finger or the hernia director into the outer part of the hernial sac, and, having closed the point of stricture, introduce a blunt-pointed straight bistoury or herniotome flatwise along the dorsum of the finger or on the director, and when it has just reached beyond the stricture turn its edge out wards and forwards so as to avoid the posterior abdominal artery which is situated to the inner side of the internal abdominal ring, and cut the stricture by a very limited incision. To facili tate this part of the procedure let an assistant draw the testicle upwards and backwards, thus bringing the seat of stricture closer to the operator. In most cases it is sufficient to cut the neck of the sac (kelotomy). The incision must be restricted, for if made too large some of the contents may pass through the opening thus made in the sac, causing false reduction. It is usually easy to return the contents after releasing the stricture. If not, reduction may be assisted by taxis per rectum. Apply the force parallel to the direction of the canal. If the bowel is ulcerated or partially necrosed the ulcer or necrosed patch may be depressed by dimpling the bowel wall at its level and shutting it off from the peritoneal cavity by means of a double row of Lembert sutures inserted on either side of it and tied across it, a procedure which is preferable to cutting out the affected part and then suturing, as the viscus is opened in this case and contamination from its lumen is apt to supervene. Burying the affected spot by suturing (enterorraphy) is only contra indicated when the lumen of the bowel is narrow, as it may then cause stenosis.
The ornentum, whether gangrenous or not, may be amputated, after ligaturing it in a healthy part, if necessary. Apply a clam round the cord outside the tunica vaginalis as before and remove the testicle.
To Preserve the Testicle. Open into the tunica vaginalis outside close to the external inguinal ring, pass the finger or director into the constricted part of the neck of the sac and cut it. Then reduce the hernia and suture the internal wound, or a piece may be removed from the tunica vaginalis at the seat of operation, and the resulting wound therein sutured so as to diminish the lumen of the entrance to the sac and perhaps prevent recurrence of the hernia. The latter may, however, appear again owing to the passage not being definitely closed.
After-treatment. As usual, place the animal in a hygienic loose box and give hospital diet. Apply an antiseptic solution to the wound once or twice daily.
Complications. The chief complication to be feared is peritonitis as the result of contamina tion during the operation, or of bacteria passing through the damaged or necrotic walls of the herniated loop of intestine. Gangrene of the bowel may occur subsequent to the operation. The dry form may supervene and not cause symptoms of peritonitis until eight to ten days afterwards, when separation has taken place and infection has consequently reached the peritoneum from the lumen of the organ. Death may result from septicemia, shock, or exhaus tion.
False Inguinal Hernia.Here the hernial contents are in the inguinal canal or scrotum, but outside the tunica vaginalis. The hernial ring is in front of the internal inguinal ring. The sac may or may not be lined by peritoneum.
The swelling appears higher up and closer to the abdominal wall than true inguinal hernia, and it has been described by Moller as having the appearance of a peaked nightcap.
Treatment. If not strangulated it is not usual to interfere. If it is necessary to treat the condition, open the sac, reduce the contents, enlarging the ring if required by cutting out wards, and suture the muscle and skin separ ately. The peritoneum is often ruptured.
Crural Hernia.A hernia through the crural arch. It is very rare in veterinary practice. It causes a swelling on the inner aspect of the thigh between the sartorius and gracilis where the saphena vein passes between these muscles, and may lead to a straddling gait. If treatment is required, proceed in the usual way and suture Poupart's ligament to the sartorius muscle. In case of strangulation be careful with the knife of the femoral artery.
Perineal Hernia.Most common in dogs, and will be dealt with in considering hernia in these, animals.
Ventral Hernia.Ventral hernia is a hernia through any part of the abdominal wall other than the umbilical and inguinal regions. It is usually caused by external violence, such as the impact of blunt bodies, but may result from muscular effort, e.g. during parturition, when it is also favoured by the distension of the abdomen.
The contents may be intestine, omentum, or both. When recent, it shows the symptoms of a contusion in addition to those of a hernia. Its most common situation is close to the last rib on the left side. Its size varies from that of a man's fist to a man's head, or, rarely, some thing larger.
Treatment is the same as for umbilical hernia, but it is not so likely to be successful here if the hernia is situated close to the ribs, where the respiratory movements render closure of the ring very difficult. One situated in the flank is in a better position for treatment than one on the abdominal floor, because the weight of the viscera in the latter case is an obstacle to union of the edges of the ring.
Ventral hernia of the size of a man's fist is often present in working horses without causing any inconvenience. In such cases operative treatment is not indicated. Sometimes the hernial ring is so large, or its lips so far apart, that operation is out of the question.
Hernia in the Ox What has been said about hernia in the horse applies in practically every detail to the same condition in the ox, in which, however, it is less common, and the veterinary surgeon may not be called to treat it except when strangulation is present or there is digestive disturbance pre venting the beast thriving.
Occasionally in calves umbilical hernia is met with, in which the contents are adherent to the sac and the patients suffer from chronic dia rrhoea, which terminates fatally after weeks or months. Inguinal hernia is not common in the ox, and is more frequently seen in the ram.
Ventral hernia is more frequent on the right than on the left side, although hernia of the rumen may occur in the latter situation.
The fourth stomach may be herniated in the lower part of the right flank between the hypo chondrium and the white line.
Hernia in the Dog and Cat Hernia as it occurs in the dog and cat is similar to that in the larger animals except that it is, of course, on a smaller scale in accordance with the difference in size of the subjects. Vomition is an important symptom of strangula tion in the carnivora.
Umbilical hernia presents in the main the characteristics as described in the horse. The size of the swelling generally varies from that of a hazel-nut to that of a walnut. The contents are small intestine or omenturn, or both. It is usually congenital and generally diminishes with age, to disappear soon after weaning.
Treatment comprises the following methods: (1) Subcutaneous injection of chloride of zinc 10 per cent aqueous solution. Seldom adopted.
(2) Use of a bandage compressing a pad applied over the orifice after reducing the hernia: but this is seldom satisfactory, as it is difficult to maintain in position.
(3) Radical operation is necessary in chronic or large hernia and in cases of incarceration and strangulation. The principles of procedure are the same as in the horse, but are executed with greater facility and more prospect of success in the small animals. Sometimes a case is met with in which the umbilical opening has closed, incarcerating a piece of omentum in the sac, where it undergoes degeneration.
Inguinal hernia is rare in the dog but common in the bitch. Its symptoms in the former are those of a hernia in the scrotal region. It has little tendency to disappear spontaneously.
To treat the condition satisfactorily it is necessary to castrate the animal by the covered method, applying an aseptic silk ligature over the tunica vaginalis and the cord as high up as possible after reducing the 'hernia.
In the bitch the hernia usually forms a more or less voluminous swelling in the inguinal region, varying in size approximately from a hen's egg to a child's head, and is fairly often double. It is generally reducible when the patient is placed in the dorsal position. Preg nancy favours its occurrence, but it may occur apart from it.
The contents are, as a rule, one or both horns of the uterus with its broad ligament, which gives a sort of corrugated feel to the swelling when manipulated. Sometimes they are formed by intestine or the bladder. The uterus may be pregnant and is then more likely to become strangulated. Otherwise strangulation is rare. Even in reducible cases the patient sometimes evinces a little pain or signs of discomfort, especially when the hernia is large. The vagina is dragged forwards by the presence of the uterus in the sac and consequently feels some what tense and stretched on digital examina tion.
The condition may be confounded with a mammary tumour, a cyst, a hematoma, or an abscess, but reducibility when possible is dia gnostic, as is also recognition of the edges of the hernial orifice. When in doubt an exploratory puncture will probably decide the matter.
Prognosis. There is no tendency to spon taneous cure. It is more likely to increase in size. It may exist for years without endanger ing the life of the patient, and when the uterus is pregnant delivery of the foetuses may occur without difficulty, or those in the herniated part may be too large to pass through the hernial ring, necessitating operative interference to remove them.
Treatment. The only successful treatment is the radical operation, which is similar to that for umbilical hernia.
Procedure. Having taken all the usual pre cautions for an abdominal operation, anaesthetize the patient and fix her in the dorsal position. Make an antero-posterior incision two to three inches long over the centre of the swelling, going through the skin and mammary gland but not through the peritoneal lining of the sac. Enu cleate the peritoneal sac as far as the hernial ring, taking care to keep close to the membrane to avoid extensive and unnecessary laceration of areolar tissue and the production of a large wound. Reduce the contents, seize the peri toneal sac with an artery forceps and twist it into a cord. Ligature the latter close to the abdominal wall, and amputate it this side of the ligature. If the ring is large insert two or three sutures through its lips. Suture the skin and seal the wound with collodion and orthoform. If the wound beneath the skin is not extensive, healing by first intention may ensue, but as a rule it takes place by second intention, the ligature and deep sutures, when present, be coming contaminated and causing suppuration, which continues until they fall or are taken away in the course of about a week.
This operation is usually a complete success, but care must be taken with delicate and toy dogs to see that they are carefully nursed and made comfortable afterwards, otherwise they may succumb to shock.
Should there be any doubt about complete reduction of the hernia the sac may be opened to make sure, and in case of adhesions, incarcera tion, or strangulation, opening it will be necessary in order to deal with the existing complication. The simplest procedure in the case of incarcer ated or strangulated uterus is to perform partial or complete hysterectomy of the empty or gravid organ, provided that the animal is not required for breeding. In the latter case, if the period for parturition has arrived, hysterotomy is indicated to remove the pups. If the ring is too small to permit of reduction of the empty uterus or other organ, incise it carefully in a forward and outward direction to enlarge it to the required extent, using a director to protect the contents from the knife. After these operations for hernia the animals must be kept quiet for some weeks, prevented from jumping from chairs, etc., for fear of rupture of the cicatrix.
The sac is formed by skin, subcutaneous tissue, and peritoneum. The latter is a pro trusion backwards of the recto-vesical or recto vaginal peritoneal cul-de-sac. Raising the fore quarters increases and raising the hind quarters diminishes the swelling. The bladder usually constitutes the contents, and being more or less bent on itself there may be stoppage of micturi tion, causing colic-like pains, vain efforts to pass urine, and increased tension and pain in the hernial swelling.
Treatment. Cut through the skin vertically over the centre of the swelling, after taking the usual precautions, and enucleate the peritoneal sac. Ligature the latter and amputate it, shorten the skin, if necessary, and suture it. Should it be impossible to separate the peri toneum for the purpose of ligation, simply remove a portion of the skin and then. suture its edges.
It will be necessary to remove the cause of the condition if possible, e.g. treat constipation or enlarged prostate.
Internal Abdominal Hernia.An internal abdominal hernia is the passage of an abdominal organ through an orifice in a membrane or parti tion inside the body.
The chief forms of internal abdominal hernia are (1) Diaphragmatic hernia, (2) Pelvic hernia.
Symptoms. The symptoms are not very char acteristic. They comprise more or less severe dyspncea from pressure on the lungs and tym pany on percussion and intestinal sounds on auscultation of the thorax.
When the protrusion into the chest cavity is slight there may be little or no interference with health. Raising the fore quarters may relieve, and raising the hind quarters may increase, the dyspncea and distress of the patient, thus accounting for the latter sometimes sitting up like a dog when suffering from this affection.
When incarceration or strangulation super venes the usual symptoms of abdominal pain are observed.
Diagnosis is difficult. The history of the case may lead one to suspect it, but in many cases it is only discovered on post-mortem examina tion. Exploratory puncture may help in this respect. Post-mortem rupture of the diaphragm often occurs from distension of the bowels with gas and consequent pressure on the part, the rent being usually in the muscular portion, whereas ante-mortem rupture more commonly occurs in the tendinous portion.
Prajnosis. When the hernia is large enough to cause functional disturbance the condition is generally serious. When a considerable weight of abdominal viscera passes into the thorax the lungs collapse at once, causing instant death. If it is only a piece of omentum that passes through a small opening and becomes adherent thereto it is of no consequence and is never diagnosed during life. Bowel may become strangulated in the orifice with fatal conse quences apart from pressure on the lungs.
Treatment is of no avail. The only rational procedure is to perform laparotomy and reduce the hernia; but a slight case is never diagnosed with sufficient certainty to justify this being done, and in a bad case it would be a foolish undertaking.
Pelvic Hernia in the Ox Synonym8. Intra-abdominal, peritoneal her nia, gut-tie, etc. Pelvic hernia is formed by the passage of a loop of bowel through a rupture in the fold of serous membrane which suspends the spermatic cord in the sublumbar and supero lateral pelvic regions; or by the compression of a piece of bowel by the spermatic cord which has returned to the abdominal cavity after castration, and become adherent to the ab dominal floor in the vicinity of the internal inguinal ring with a portion of the viscera caught between it and the abdominal wall. Castration with violent traction of the cord causes the rupture in its membrane or severs the cord high up, allowing the end to recede into the abdomen and behave as described. The condition occurs on the right side, the presence of the rumen on the left side preventing its occurrence there.
It prevails in mountainous districts, the ascent of heights throwing the abdominal contents backwards and favouring the lesion. Abnormal distension of the rumen also predisposes by increasing the intra-abdominal pressure on the right side. It is well known in some parts of England, is common in Germany, and is rare in France and Italy.
Symptoms. When not strangulated it causes no symptoms, but when strangulation takes place it is manifested by abdominal pain and by signs of intestinal obstruction, the animal becoming uneasy, lying down and getting up, looking round at the side and making vain efforts at defeecation, passing only particles of faeces or simply mucus. Enemata are expelled immediately. It is diagnosed on rectal ex amination, which reveals the presence of a soft, doughy sort of swelling at the entrance to the pelvis on the right side near the sacrum, slightly painful on pressure, and of variable size, and due to the strangulated loop of bowel. The tense, stretched spermatic cord may also be felt.
Prognostis. If relief is not forthcoming the strangulated portion of bowel will become gangrenous, and death will ensue on the fourth or fifth day, or, rarely, it may be delayed until the second week after the accident.
Treatment. Treatment comprises: (1) Jump ing the animal from a height or making it descend rapidly a steep incline. (2) Applying taxis per rectum to draw the herniated portion of bowel out of the orifice. (3) Performing laparotomy to rupture or cut the spermatic cord and release the incarcerated bowel.
The first method of treatment is worth trying in a recent case, as it may succeed when the constriction is slight and no adhesions are present. It offers no safeguard against recurrence of the condition. Taxis per rectum may be successful if the hernia is small and not tightly wedged in the opening. The animal should be controlled, standing with the fore quarters on a lower level than the hind ones to facilitate escape of the bowel from the stricture. The third procedure is the surest and should be done at once in cases of some standing, before the animal is exhausted or gangrene has set in.
It consists in performing laparotomy in the right flank, and introducing the hand into the abdomen to rupture the cord with the finger, or to cut it by means of a hooked knife with a blunt point and a sharp edge on its concavity introduced into the hernial opening, the wound in the abdominal wall being afterwards closed in the usual way. When the operation is done fairly early, before serious alteration has occurred in the bowel, it is usually successful.