Hernia

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By the term hernia is meant the protrusion beyond its normal position of some part or structure of one of the body cavities. When used without any special qualifications, the term is understood to mean an external abdominal (inguinal) hernia, or rupture. This type accounts for over 90 per cent of all hernias in men and 50 per cent of all hernias in women, in whom femoral hernia is much commoner than in men. Next in frequency come post-operation hernias, or hernias through weak operation scars in the abdominal wall. These account for nearly 10 per cent. Hernia of the navel (umbilical hernia) is not uncommon in infancy.

External Abdominal (Inguinal) Hernia

External abdominal hernia is a very common complaint especially amongst those engaged in strenuous occupations. In men, it is closely associated with the passage by which the testis in early life descends from the abdominal cavity into the scrotum, and in advanced forms of rupture the contents of the hernial sac may occupy one side of the scrotal sac. The contents of a hernia usually consists of folds of peritoneum (omentum) or small intestine, or both. A hernia may be wholly or partly reducible, or it may be irreducible, the contents being retained in the sac by reason of their bulk or by a constriction at the neck of the sac, or by adhesions between the contents and the wall of the sac.

Symptoms. As a rule the patient notices some slight discomfort which draws attention to the part in which an abnormal swelling is found. Such a swelling may be present only intermittently, and in the early stages it usually disappears when the patient lies down. Often there is a feeling of weakness or insecurity in the region of the groin.

Some hernias are present from birth. Others appear suddenly later in life, usually after some strain, whilst the remainder appear gradually and are first recognised as an unusual swelling or lump. Once it has appeared, a hernia tends to become pro-gressively larger.

Hernia is rarely associated with acute pain unless it becomes strangulated, but may give rise to constipation and dyspepsia or nausea.

An abdominal hernia forms an external swelling which is usually soft and compressible. When it can be reduced, i.e. returned to the abdomen, the process is sometimes accompanied by a gurgling of intestinal gas and liquid. The swelling gives an impulse on coughing which can be both seen and felt by the person examining the swelling.

Complications

Obstruction . A hernia may become obstructed in the sense that the contents of the bowel in the sac do not pass on. The condition may often be relieved by enemas assisted by manipulation of the hernia, after ensuring by catheterisation that the bladder is empty.

Strangulation. If an obstructed hernia cannot be reduced, there is a risk that it may become strangulated, from increased bulk of the contents of the sac.

Acute strangulation is due to congestion which leads to complete stagnation of the circulation in the contents of the sac, which, if not relieved by operation, results in gangrene of the bowel. It is one of the commonest causes of acute intestinal obstruction.

The onset is usually heralded by an attack of pain which is at first referred to the navel and is later felt in the hernia. The hernia becomes larger than it has ever been before. It is hard and tender, and cannot be reduced.

Any attempts to obtain an action of the bowels by means of medicines or enemas are unsuccessful, while an attempt to take food immediately brings on an attack of colic and vomiting. Once a hernia has become strangulated, immediate operation is necessary.

Treatment. Cure By Operation. The most satisfactory treatment for all hernias is by operation, which should always be advised unless there is a strong contraindication. In early cases, and in skilled hands, operation can cure, and will rid the patient in a short space of time of a disability which might otherwise last a lifetime and which may, with increasing years, become a danger.

Contraindications to operation are few, but it should not be undertaken before a persistent cough has been brought under control, or in cases of uncontrolled diabetes mellitus, or of great or increasing obesity.

Truss. Only a hernia which is completely reducible can be controlled with a truss. It must be able to retain a hernia in all positions of the body and in the presence of ordinary stresses such as coughing, sneezing and laughing. The real test of a truss is its ability to retain the hernia while the patient sits on the edge of a chair with the trunk bent fully forward, and the legs widely separated. If in this position the hernia is retained during coughing, the truss is likely to prove efficient. The object of a truss is to prevent the hernia from ever coming down. It must therefore be applied before the patient rises in the morning, and it should not be removed before he lies down at night.

Umbilical Hernia

Hernia of the navel is not uncommon in infants, and it often appears when the child is a few weeks old. Two matters are important in the management of the condition.

Firstly, all causes of abnormal abdominal distension should be discovered and removed, and secondly, crying should be reduced to a minimum. Pressure should be applied over the protuberance by means of a small flat pad. A 2-pence wrapped in lint is very suitable for the purpose. It must be firmly fixed over the site of the hernia by strapping and kept in position continuously for three to six months, though the strapping may be renewed every week or two. If this does not result in cure, or if the condition recurs, an operation should be undertaken after the child has reached the age of two years. Most hernias of this type disappear spontaneously, however, with-in the first year of life.

Diaphragmatic Hernia

(Hiatus Hernia)

In diaphragmatic hernia there is protrusion of the abdominal contents through the diaphragm into the thorax. The reverse never occurs. The opening through which the oesophagus passes is the most vulnerable part of the diaphragm, and it is through this opening that most hernias of the diaphragm occur. This condition is fairly common and may simulate almost any upper abdominal disorder. The contents are usually composed of the upper part of the stomach.

Symptoms. The chief symptom is burning pain after food, and particularly on lying down, which may prevent the patient from sleeping or may actually waken him from sleep. It is due to the acid of the gastric juice rising into the oesophagus and irritating the mucous membrane in its lower third. In severe cases it may be associated with actual ulceration and bleeding.

Persistent vomiting in young infants is sometimes due to this disorder; it can be con-firmed by X-ray diagnosis.

Heartburn is a common symptom during the later months of pregnancy, and is due to herniation of the stomach resulting from increased pressure caused by the enlarged uterus. The symptom usually disappears after delivery.

Treatment. This consists in raising the head of the bed on wooden blocks nine inches high, the patient being propped up with pillows during the night. Antacids should be given, combined at night with atropine or with one of the synthetic antispasmodics (Kolantyl, or Pro-Banthine). Mucaine combines the antacid effects of aluminium and magnesium hydroxide with a local anaesthetic. The dose is one or two 5-ml spoonfuls four times a day, 15 minutes before meals and at bedtime.

Source : Family Physician

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