Hernia

Hernia (Lat. hernia, perhaps from Gr. ἔρνος, a sprout), in surgery, the protrusion of a viscus, or part of a viscus, from its normal cavity; thus, hernia cerebri is a protrusion of brain-substance, hernia pulmonum, a protrusion of a portion of lung, and hernia iridis, a protrusion of some of the iris through an aperture in the cornea. But, used by itself, hernia implies a protrusion from the abdominal cavity, or, in common language, a “rupture.” A rupture may occur at any weak point in the abdominal wall. The common situations are the groin (inguinal hernia), the upper part of the thigh (femoral hernia), and the navel (umbilical hernia). The more movable the viscus the greater the liability to protrusion, and therefore one commonly finds some of the small intestine, or of the fatty apron (omentum), in the hernia. The tumour may contain intestine alone (enterocele), omentum alone (epiplocele), or both intestine and omentum (entero-epiplocele). The predisposing cause of rupture is abnormal length of the suspensory membrane of the bowel (the mesentery), or of the omentum, in conjunction with some weak spot in the abdominal wall, as in an inguinal hernia, which descends along the canal in which the spermatic cord lies in the male and the round ligament of the womb in the female. A femoral hernia comes through a weak spot in the abdomen to the inner side of the great femoral vessels; a ventral hernia takes place by the yielding of the scar tissue left after an operation for appendicitis or ovarian disease. The exciting cause of hernia is generally some over-exertion, as in lifting a heavy weight, jumping off a high wall, straining (as in difficult micturition), constipation or excessive coughing. The pressure of the diaphragm above and the abdominal wall in front acting on the abdominal viscera causes a protrusion at the weakest point.

Rupture is either congenital or acquired. A child may be born with a hernia in the inguinal or umbilical region, the result of an arrest of development in these parts; or the rupture may be acquired, first appearing, perhaps, in adult life as the result of a strain or hurt. Men suffer more frequently than women, because of their physical labours, because they are more liable to accidents, and because of the passage for the spermatic cord out of the abdomen being more spacious than that for the round ligament of the womb.

At first the rupture is small, and it gradually increases in bulk. It varies from the size of a marble to a child’s head. The swelling consists of three parts—the coverings, sac and contents. The “coverings” are the structures which form the abdominal wall at the part where the rupture occurs. In femoral hernia the coverings are the structures at the upper part of the thigh which are stretched, thinned and matted together as the result of pressure; in other cases there is an increase in their thickness, the result of repeated attacks of inflammation. The “sac” is composed of the peritoneum or membrane lining the abdominal cavity; in some rare cases the sac is wanting. The neck of the sac is the narrowed portion where the peritoneum forming the sac becomes continuous with the general peritoneal cavity. The neck of the sac is often thickened, indurated and adherent to surrounding parts, the result of chronic inflammation. The “contents” are bowel, omental fat, or, in children, an ovary.

The hernia may be reducible, irreducible or strangulated. A “reducible” hernia is one in which the contents can be pushed back into the abdomen. In some cases this reduction is effected with ease, in others it is a matter of great difficulty. At any moment a reducible hernia may become “irreducible,” that is to say, it cannot be pushed back into the abdominal cavity, perhaps because of inflammatory adhesions in and around the fatty contents, or because of extra fullness of the bowel in the sac. A “strangulated” hernia is one in which the circulation of the blood through the hernial contents is interfered with, by the pinching at the narrowest part of the passage. The interference is at first slight, but it quickly becomes more pronounced; the pinched bowel in the hernial sac swells as a finger does when a string is tightly wound round its base. At first there is congestion, and this may go on to inflammation, to infection by micro-organisms and to mortification. The rapidity with which the change from simple congestion to mortification takes place depends on the tightness of the constriction, and on the virulence of the bacterial infection from the bowel. As a rule, the more rapidly a hernia forms the greater the rapidity of serious change in the conditions of the bowel or omentum, and the more urgent are the symptoms. The constricting band may be one of the structures which form the boundaries of the openings through which the hernia has travelled, or it may be the neck of the sac, which has become thickened in consequence of inflammation—especially is this the case in an inguinal hernia.

Reducible Hernia.—With a reducible hernia there is a soft compressible tumour (elastic when it contains intestine, doughy when it contains omentum), its size increasing in the erect, and diminishing in the horizontal posture. As a rule, it causes no trouble during the night. It gives an impulse on coughing, and when the intestinal contents are pushed back into the abdomen a gurgling sensation is perceptible by the fingers. Such a tumour may be met with in any part of the abdominal wall, but the chief situations are as follows. The inguinal region, in which the neck of the tumour lies immediately above Poupart’s ligament (a cord-like ligamentous structure which can be felt stretching from the front of the hip-bone to a ridge of bone immediately above the genital organs); the femoral region, in the upper part of the thigh, in which the neck of the sac lies immediately below the inner end of Poupart’s ligament; the umbilical region, in which the tumour appears at or near the navel. As the inguinal hernia increases in size it passes into the scrotum in the male, into the labium in the female; while the femoral hernia gradually pushes upwards to the abdomen.

The palliative treatment of a reducible hernia consists in pushing back the contents of the tumour into the abdomen and applying a truss or elastic bandage to prevent their again escaping. The younger the patient the more chance there is of the truss acting as a curative agent. The truss may generally be left off at night, but it should be put on in the morning before the patient leaves his bed. If, after the hernia has been once returned, it is not allowed again to come down, there is a probability of an actual cure taking place; but if it is allowed to come down occasionally, as it may do, even during the night, in consequence of a cough, or from the patient turning suddenly in bed, the weak spot is again opened out, and the improvement which might have been going on for weeks is undone. It is sometimes found impossible to keep up a hernia by means of a truss, and an operation becomes necessary. The operation is spoken of as “the radical treatment of hernia,” in contra-distinction to the so-called “palliative treatment” by means of a truss. It should not be spoken of as the radical cure, for skilfully as the operation may have been performed it is not always a cure. The principles involved in the operation are the emptying of the sac and its entire removal, and the closure of the opening into the abdomen by strong sutures; and, in this way, great advance has been made by modern surgery. Without tiresome delay, and the tedious and sometimes disappointing application of trusses, the weak spot in the abdominal wall is exposed, the sac of the hernia is tied and removed, and the canal by which the rupture descended is blockaded by buried sutures, and with no material risk to life. Thus the patient’s worries become a thing of the past, and he is rendered a fit and normal member of society. Experience has shown that very few ruptures are unsuited for successful treatment by operation. No boy should now be sent to school compelled to wear a truss, and so hindered in his games and rendered an object of remark.

Irreducible Hernia.—The main symptom is a tumour in one of the situations already referred to, of long standing and perhaps of large size, in which the contents of the tumour, in whole or in part, cannot be pushed back into the abdomen. The irreducibility is due either to its large size or to changes which have taken place by indurations or adhesions. Such a tumour is a constant source of danger: its contents are liable, from their exposed situation, to injury from external violence; it has a constant risk of increase; it may at any time become strangulated, or the contents may inflame, and strangulation may occur secondarily to the inflammation. It gives rise to dragging sensations (referred to the abdomen), colic, dyspepsia and constipation, which may lead to obstruction, that is to say, a stoppage may occur of the passage of the contents of that portion of the intestinal canal which lies in the hernia. When an irreducible hernia becomes painful and tender, a local peritonitis has occurred, which resembles in many of its symptoms a case of strangulation, and must be regarded with suspicion and anxiety. Indeed, the only safe treatment is by operation.

The treatment of irreducible hernia may be palliative; a “bag truss” may be worn in the hope of preventing the hernia getting larger; the bowels must be kept open, and all irregularities of diet avoided. A person with such a hernia is in constant danger, and if his general condition does not contra-indicate it he should be submitted to operative treatment. That is to say, the surgeon should cut down on the hernia, open the sac, divide any omental adhesions, tie and cut away indurated omentum, return the bowel, and complete the radical operation by closing the aperture by strong sutures.

In Strangulated Hernia the bowel or omentum is being nipped at the neck of the sac, and the flow of blood into and from the delicate tissues is stopped. The symptoms are—nausea, vomiting of bilious matter, and after a time of faecal-smelling matter; a twisting, burning pain generally referred to the region of the navel, intestinal obstruction; a quick, wiry pulse and pain on pressure over the tumour; the expression grows anxious, the abdomen becomes tense and drum-like, and there is no impulse in the tumour on coughing, because its contents are practically pinched off from the general abdominal cavity. Sometimes there is complete absence of pain and tenderness in the hernia itself, and in an aged person all the symptoms may be very slight. Sooner or later, from eight hours to eight days, if the strangulation is unrelieved, the tumour becomes livid, crackling with gas, mortification of the bowel at the neck of the sac takes place, followed by extravasation of the intestinal contents into the abdominal cavity; the patient has hiccough; he becomes collapsed; and dies comatose from blood-poisoning.

The treatment of a strangulated hernia admits of no delay; if the hernia does not “go back” on the surgeon trying to reduce it, it must be operated on at once, the constriction being relieved, the bowel returned and the opening closed. There should be no treatment by hot-bath or ice-bag: operation is urgently needed. An anaesthetic should be administered, and perhaps one gentle attempt to return the contents by pressure (termed “taxis”) may be made, but no prolonged attempts are justifiable, because the condition of the hernial contents may be such that they cannot bear the pressure of the fingers. “Think well of the hernia,” says the aphorism, “which has been little handled.”

The taxis to be successful should be made in a direction opposite to the one in which the hernia has come down. The inguinal hernia should be pressed upwards, outwards and backwards, the femoral hernia downwards, backwards and upwards. The larger the hernia the greater is the chance of success by taxis, and the smaller the hernia the greater the risk of its being injured by manipulation and delay. In every case the handling must be absolutely gentle. If taxis does not succeed the surgeon must at once cut down on the tumour, carefully dividing the different coverings until he reaches the sac. The sac is then opened, the constriction divided, care being taken not to injure the bowel. The bowel must be examined before it is returned into the abdomen, and if its lustreless appearance, its dusky colour, or its smell, suggests that it is mortified, or is on the point of mortifying, it must not be put back or perforation would give rise to septic peritonitis which would probably have a fatal ending. In such a case the damaged piece of bowel must be resected and the healthy ends of the bowel joined together by fine suturing. Matted or diseased omentum must be tied off and removed. Should peritonitis supervene after the operation on account of bacillary infection, the bowels should be quickly made to act by repeated doses of Epsom salts in hot water.

A person who is the subject of a reducible hernia should take great care to obtain an accurately fitting truss, and should remember that whenever symptoms resembling in any degree those of strangulation occur, delay in treatment may prove fatal. A surgeon should at once be communicated with, and he should come prepared to operate.

(E. O.*)

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