Hernia

“ A hernia is reducible when the displaced organ can be returned to its natural location. It consists of a soft swelling, without heat, pain, or any uneasiness, generally larger on full feed, and decreases in size as the bowels become empty. An irreducible hernia is one that can not be returned into the abdomen, and yet does not cause any pain or uneasiness. ”

“ 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. ”

“ 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 ”

“ Formerly the hernia was retained with a truss, but of late years it had been allowed to go up and down according to circumstances, never having become strangulated before. Now, my experience has been that when an old man who has had years of practice reducing his hernia fails to put it back, the surgeon has a job on his hands. ”

“ A good deal will depend on whether any one is present when the hernia happens, as to the possibilities of a perfect cure. Umbilical hernia, or diaphragmatic hernia, calls for the most skilled treatment, and even then little or nothing can be done. ”

“ 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. ”

“ 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 ”

“ The prognosis is always serious, on account of possible complications, due to strangulation of the herniated loop. When the hernia is 495chronic, reduction is much more difficult, there being, as a rule, adhesions between the intestine and the hernial sac. ”

“ A protrusion of a loop or portion of intestine through a weakened abdominal muscle—which grows larger when baby cries and smaller when he is lying down in a relaxed condition—is known as rupture or hernia, and is of common occurrence in infancy. It is often seen at the navel and sometimes in the groin as early as the second week.
Hernia is always dangerous and should never be neglected. The physician will protect the navel by a special support with adhesive plaster which is carefully renewed twice a week, and if worn for several months usually entirely corrects the condition. ”

“ More than two-thirds of cases of rupture suffer from inguinal hernia In the oblique form of inguinal hernia the abdominal contents descend along the inguinal canal to the outer side of the epigastric artery, and enter the scrotum in the male, and the labium majus in the female. In this form of hernia the size of the sac is sometimes enormous, the accompanying illustration showing extreme cases of both scrotal and labial hernia. Umbilical hernia may be classed under three heads: congenital, infantile, and adult. ”

“ It is distinguished from hernia by the fact that in hernia pain is felt in the testicle, radiating to the kidneys, while in rupture of the siphac a swelling on one side of the pubes extends into the scrotum, where it produces a tumor not involving the testicle. Rupture of the siphac, he says, is a lesion of the organs of nutrition, hernia a disease of the organs of generation. Accordingly, in the pathology of Gilbert, the term hernia is applied to hydrocele, orchitis and other diseases of the testicle, and not, as with us to protrusions of the viscera through the walls of their cavities. ”

“ 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 ”

“ Hernia of the stomach is not uncommon, especially in diaphragmatic or umbilical deficiency. There are many cases on record, some terminating fatally from strangulation or exposure to traumatism. Paterson reports a case of congenital hernia of the stomach into the left portion of the thoracic cavity. It was covered with fat and occupied the whole left half of the thoracic cavity. The spleen, pancreas, and transverse colon were also superior to the diaphragm. Death was caused by a well-defined round perforation at the cardiac curvature the size of a sixpence. ”

“ But if there be any disease which, from the frequency of its occurrence, from the variety of its forms, from the difficulty of discriminating between it, and other maladies, and from the danger attendant on almost all its varieties, requires a combination of the most minute investigation, with the most accurate anatomical knowledge, it is that of hernia. ”

“ The hernia is caused by the absence of proper umbilical attention and abdominal support to the child after parturition. Umbilical hernia is fearfully common all through Africa, I having frequently seen persons, especially females, with the hernial tumor as large as their own head, and those of little children fully as large as the head of an infant a month old. ”

“ Devergie relates the case where a person lived nine months with the stomach and colon in the chest and died from another cause. Thus a person may have a phrenic hernia and die from another cause, or having had a rupture or wound of the diaphragm he may suddenly acquire a diaphragmatic hernia by reason of a blow or sudden exertion, or the latter may strangulate an existing hernia. A person with a diaphragmatic hernia may have the power of moving or walking, but is more or less incapacitated owing to the compression of the lungs which exists and the consequent dyspnœa, etc. ”

“ In recent traumatic hernia there is swelling on the left side of the lower part of the abdomen. The swelling is greatest in the cases of hernia which are situated on the lower part of the abdomen. Unless an examination is made immediately after the injury has been inflicted it is difficult, and sometimes impossible, to ascertain the exact extent of the rupture, owing to the swelling which subsequently takes place. Frequently there is no loss of appetite, fever, or other general symptoms attending the injury. ”

“ While he discussed hernia operations so freely, the great French surgeon did not believe that everyone who suffered from a hernia ought to be submitted to an operation. He quite agreed with Mondeville who, in the preceding generation, declared that many operations for hernia were done not for the benefit of the patient but for the benefit of the surgeon—a mode of expression that is likely to strike a sympathetic chord in some physicians’ minds even at the present time. ”

“ In cases of strangulated hernia, could acupuncture, or puncture with a capillary trocar, be used with safety and advantage to give exit to air contained in the strangulated bowel? Or to stimulate it into action? It is not uncommon for bashful men to conceal their being afflicted with a small hernia, which is the cause of their death ”

“ Any thing which occasions general or local muscular debility, as dropsy, pregnancy, abscesses, wounds, obstructions to natural evacuations, etc., is a predisposing cause of hernia. The exciting cause is pressure applied to the contents of the abdomen, as straining in evacuating the bowels and bladder, lifting heavy weights, or violent physical exertion. ”

“ It is in relation to the epigastric artery alone that the direct hernia differs essentially from the oblique variety; for I find that both may be enclosed in the same structures as invest the spermatic vessels.
The external ring of the male groin is larger than that of the female; and this circumstance, with others of a like nature, may account for the fact, that the female is very rarely the subject of the direct hernia. In the male, the direct hernia is found to occur much less frequently than the oblique, and this we might, a priori, expect, from the anatomical disposition of the parts. ”

“ At the same time, the surgeon must bear in mind that pain of the abdomen, with symptoms resembling those of strangulation—in fact, that enteritis, with obstruction, may exist along with hernia, but independent of it. A person with hernia is as liable as any other, if not more so, to inflammatory attacks in the abdomen from a variety of causes. The portion of bowel in the tumour may participate or not in the general abdominal affection ”

“ Thus with respect to the conjoined tendon, the hernia is said, in some instances, to take an investment of this structure; in others, to pass through a cleft in its fibres; in others, to escape by its outer margin. Again, the cremaster muscle is stated by some to cover this hernia; by others, to be rarely met with, as forming one of its coverings; and by others, never. Lastly, it is doubted by some whether this hernia is even covered by a protrusion of the fascia transversalis in all instances. ”

“ 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 most serious cases of such injury to the diaphragm are due to violent contusions or falls when the stomach and intestines are full. The hemorrhage is usually slight, but hernia of one or more of the abdominal viscera usually occurs in such cases, and is said to be more readily produced during inspiration when the fibres are on the stretch. According to Devergie, rupture of the diaphragm with hernia is more common on the left side in the central tendon in front of the crura and at the junction of the left muscular leaflet. ”

“ 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 ”

“ Other forms of hernia are so rare, and the treatment of each case must necessarily vary so much in its circumstances, as not to require or admit of any detailed account of the operations requisite for their relief. ”

“ The retention of fæces in the region of the scrotum often brings on dangerous symptoms; [373] for it is attended with pain, and sometimes with rumbling of wind upon pressure. The peculiar symptoms of hernia from distension are, that it does not occur suddenly, but gradually; that it falls down occasionally from any ordinary causes; that the swelling appears equable and deep-seated, the protruded intestine being surrounded by the peritoneum. In those from rupture the descent at first is sudden, and happens only from violence ”

“ In an intestinal hernia the swelling is usually not painful, of a doughy consistence or elastic, according as the intestine does or does not contain alimentary matter. This swelling can generally be made to disappear by pressure, and when it has been reduced one can easily recognize the direction and extent of the hernial opening. Hernias of the bowel which are situated at the upper and right side of the abdomen are usually formed by the small intestine. ”

“ Again, if the hernia enter the inguinal wall close to the epigastric artery, it will find its way into the inguinal canal, become invested by the structures forming this part, and here it may suffer active constriction from the muscular fibres of the transverse and internal oblique or their cremasteric parts. The external ring may be considered as always causing some degree of pressure on the hernia which passes through it. ”

“ Hernia can seldom be mistaken for any other swelling, by one at all acquainted with his profession, and who makes his examination attentively. The history, and the mode of its appearance, are to be attended to. The swelling proceeds from above—at times it recedes on the patient lying on his back and making pressure on the swelling—a distinct impulse is communicated to it on exertion of the abdominal muscles, as in coughing—the tumour is generally elastic, and its neck can be felt extending from the lower abdominal aperture. ”