Hernia

HERNIA, in surgery, the protrusion of a part 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. As a result of X-ray examinations herniae of abdominal viscera into the thorax through a defect in the diaphragm have been recognized with some frequency. But, used by itself, hernia implies, in common language, a "rupture." A rupture may occur at any weak point in the abdominal wall. The common situations are the groin (inguinal), the upper part of the thigh (femoral), and the navel (umbilical). The hernia may contain intestine alone, omentum alone, or both. The predisposing cause of rupture is abnormal length of the mesentery or of the omentum, together 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 abdominal operation. The exciting cause of hernia is generally over-exertion, as in lifting a heavy weight, jumping off a high wall, straining, con stipation, 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, owing to defective development in those parts; or the rupture may first appear, per haps, in adult life as the result of a strain or hurt. Men suffer more often than women, because of their physical labours and greater liability to accidents, and because the canal for the spermatic cord out of the abdomen is wider than that for the round ligament of the womb.

At first a rupture is small but it gradually increases in bulk. It varies in size from a marble to a child's head. The swelling con sists of three parts—the coverings, sac, and contents. The "cover ings" are the structures which form the abdominal wall at the part where the rupture occurs, thinned and matted together as the re sult of pressure or thickened from repeated attacks of inflamma tion. 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 reduction is easy, in others, a matter of great difficulty. At any moment a reducible hernia may become "irreducible," perhaps from inflammatory adhesions in and around the fatty contents, or from extra fullness of the bowel in the sac. A "strangulated" hernia is one in which the circulation of blood through the hernial contents is impeded by the pinching at the narrowest part of the passage. The interfer ence is at first slight, but quickly becomes pronounced; the pinched bowel in the hernial sac swells as a finger does when a string is tightly wound round its base. Congestion is followed by inflam mation, infection by micro-organisms and mortification. The rapidity with which these changes take place depends on the tight ness of the constriction. 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 already given. Inguinal hernia is commoner in men, femoral, in women. As an inguinal hernia increases in size it passes into the scrotum in the male, into the labium in the female ; while a femoral hernia gradually pushes upwards to the abdomen.

The palliative treatment of a reducible hernia consists in push ing back the contents of the tumour into the abdomen and apply ing 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 impos sible 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 contradistinction to the so-called "pallia tive treatment" by means of a truss. 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. Experience has shown that very few ruptures are un suited for radical treatment by operation.

Irreducible Hernia.—The main symptom is a swelling 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 hernia is a constant source of danger; its contents are liable to injury from external violence; it may at any time become strangulated, or the contents may inflame, and strangulation may occur secondarily to the inflam mation. It gives rise to dragging sensations (referred to the abdomen), colic, dyspepsia, and constipation, which may lead to stoppage of the passage of the contents through that portion of the intestinal canal which lies in the hernia. When an irre ducible 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. But it must be repeated that a person with such a hernia is in constant danger, and if possible a radical operation should be done.

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 com plete 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 un relieved, the tumour becomes livid, crackling with gas, mortifica tion 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 ; it

must be operated on at once. There should be no attempt at 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 may be made, but no pro longed attempts are justifiable, because the condition of the hernial contents may be such that they cannot bear the pressure of the fingers.

Attempts at replacement 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 up wards. The larger the hernia the greater is the chance of success, 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 it does not succeed the surgeon must at once cut down on the swelling, 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 mortify ing, it must not be put back or perforation would give rise to septic peritonitis, which probably would 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 sutur ing. Matted or diseased omentum must be tied off and removed.