Thursday, October 29, 2009

1908 View of Hernias – Dx and Tx

The section of the 1908 textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD on hernias is very interesting.

Hernia --

A hernial sac is a protrusion of a part of the peritoneum through an opening in the abdominal wall. In this sac there may or may not be found portions of the abdominal organs. If they can be “replaced” in the abdominal cavity the hernia is called “reducible.” Otherwise it is an “irreducible” hernia. Such reduction may be impossible on account of altered shape of the organs in the sac, its “contents,” so-called, or on account of adhesions which have formed around the sac and its contents. The hernia may become inflamed as a result of traumatism, etc. This rarely leads to suppuration. It may produce so much swelling of the hernial contents that the blood-vessels which supply them are occluded, and strangulation results.

A hernia may exist at birth or develop soon afterward in an abnormally weak spot in the abdominal wall. It may also appear in later life, either suddenly, following some crush or severe strain, or gradually, as the result of oft repeated lesser strains.

The subject of hernia, and especially its operative treatment, is exhaustively discussed in works upon major surgery. Still, the general means of correct diagnosis and the ambulant treatment of patients who, for one reason or another, cannot be operated upon, are here in place.

General Principles of Diagnosis --

A patient suspected to have a hernia should be examined in both standing and recumbent postures.

Inspection may show variation in size at different times if the hernia is reducible. Peristaltic movements are often visible in large intestinal hernias.

Palpation may reveal the presence of intestinal coils, of gurgling gas and fluid, of lumpy omentum, or of pasty fecal masses capable of being indented.

Compression, when the patient is recumbent, may affect the reduction of the hernia.

Percussion will bring out the resonance of intestinal coils containing gas. It will also give a thrill in case the swelling is due to a hydrocele or a cold abscess.

Auscultation may reveal an intestinal gurgle or, in rare cases, an aneurysmal thrill.

An impulse on coughing is obtained in case of most herniae. It may also be obtained, though less marked, in case of a large varicocele or in case of a hydrocele which extends well up into the inguinal canal.

Reduction of the swelling upon compression or spontaneously when the patient lie down is very significant of hernia, but may also occur with an imperfectly descended testis or a cold abscess.

General Principles of Treatment --

Operation of hernia, wherever situated, to be successful must accomplish these three steps:

1. The reduction of the hernial contents, either before or after the sac has been opened.

2. The closure of the peritoneal cavity at the normal level. The sac is usually tied at this point, its neck, and the surplus removed.

3. The approximation by firm sutures of the damaged wall of the abdomen, or at the least of its strongest part, namely, the deep fascia.

The various methods of accomplishing these three steps vary in different situations and in the hands of different operators. They are fully described in all surgical text-books.

If the condition of the patient and the character of the hernia make it probable that the three steps above described can be carried out by operation, and primary union attained, operation should be advised. It is, of course, absolutely indicated in case of strangulated hernia as a relief of acute symptoms, even under circumstances in which a permanent cure of the hernia is not to be expected.

A truss is to be recommended in all other cases of reducible hernia. A patient having an irreducible, inoperable hernia is indeed in a bad state. Some of them gain relief by an operation which changes the hernia from an irreducible to a reducible one, so that a truss can be worn. An unusual type of partly reducible hernia is shown in Figure 111.

The symptoms of hernia in different situations vary greatly. A brief description is therefore given of each.

Umbilical Hernia --

Hernia of the umbilicus in the new-born is extremely common. The sac is usually small and contains intestine or is empty. This hernia has a strong tendency toward recovery, but to facilitate this end it should be constantly kept pressed back by means of a cloth-covered, wooden button-mold and a short strip of adhesive plaster. This should be changed every day or every second day after the infant’s bath, but before the old one is removed the new one should be prepared, and in the interval the hernia should be pressed back by the nurse’s finger until the new button is put in place. The plaster should extend in a different direction every day so that the skin may not become irritated. If treated in this manner the great majority of infantile umbilical herniae can be cured in a few months.

Umbilical hernia in the adult is especially common in stout persons of middle age. It first appears as a flabby tumor as large as the terminal joint of the finger, covered with normal skin. It is usually irreducible. Its contents are omentum. As it grows the sac becomes more distended; small intestine will often be added to the omental contents. This part of the hernia is usually reducible, at least for a considerable period. Such a hernia frequently becomes strangulated.

A truss is an unsatisfactory appliance for umbilical hernia of the adult. An operation should be performed early, if possible before intestine is involved.

Inguinal Hernia --

Inguinal hernia is more common than femoral hernia both in the male (39 to 1) and female (3 to 2); or, to put it differently, for every 84 inguinal hernias in the male there are 8 inguinal hernias in the female, 6 femoral hernias in the female, and 2 femoral hernias in the male. It is usually indirect, that is to say, the omentum, intestine, etc., which fills its sac leaves the abdomen by the normal route of the inguinal canal, and does not burst through the posterior wall of the inguinal canal to the median side to the epigastric artery (direct inguinal hernia).

Inguinal hernia may be congenital or acquired, and if acquired it may develop suddenly as the result of a crush or strain, or slowly.

Symptoms – These symptoms are usually present: normal moveable skin; underlying tumor giving impulse on coughing, growing smaller or disappearing entirely under pressure or on lying down; enlarged ring and inguinal canal evident on reduction of tumor; reduced tumor does not reappear when patient stands and coughs if the canal is blocked by the surgeon’s finger; no true fluctuation; opacity to transmitted light.

Possible additional symptoms of intestinal hernia are: resonance on percussion, gurgling on manipulation, indentation of doughy fecal masses in large intestine.

Treatment – Treatment by operation entails only a slight risk, and is generally successful. It should therefore be advised in the case of all healthy children and active adults. Treatment by truss is advisable for feeble and aged persons and for those whose tissues in the inguinal region are so thinned by previous unsuccessful operation that they cannot be made to withstand the intra-abdominal pressure.

A truss is a pad held firmly against the lower part of the inguinal canal to prevent the exit of the omentum, etc., from the abdominal cavity. It has been well compared to the stopper of a bottle. Opinions differ as to the best form of truss. A satisfactory truss is one which, with a minimum of pressure and without causing the patient any pain, prevents the hernial contents from entering the hernial sac.

The hernia must be fully reduced before a truss is applied. This is best done when the patient lies on his back. A truss should never be applied to a hernia which is only partially reducible. It will rarely succeed in keeping back the rest of the hernial contents, and by its pressure on the part already in the sac it will cause pain and possibly serious inflammation, or even gangrene.

A truss is rarely needed in case of a very young infant; but before the child is old enough to walk it should be fitted with a truss or should be operated upon. Operation is advisable for large congenital herniae, as cure is improbable when the neck of the sac is so wide. If the tunica vaginalis communicates with the peritoneal cavity by a rather narrow passage, and the contents of the hernial sac can be reduced into the abdomen without dragging the testicle upward, a truss may cure the patient in the course of a few years. For this purpose it should be worn constantly day and night, as crying no less than walking will force the abdominal organs into the hernial sac. As the child grows older the truss may be left off at night, and if the neck of the sac becomes obliterated the truss need only be worn during exercise, and finally not at all. A cure is sometimes obtained from a truss in adult life, but is far less likely after the patient has attained his growth.

Femoral Hernia --

In femoral hernia the protrusion of abdominal contents is under Poupart’s ligament and through the femoral ring. Such a hernia is usually small, and this fact, added to the tortuous course of the canal, sometimes obscures the impulse on coughing and renders diagnosis difficult. An enlarged lymphatic gland, with which femoral hernia is often confounded, if unilateral has almost always an evident cause in some scratch or cut of the foot or leg.

Femoral hernia should always be treated by operation.

Strangulated hernia

always requires treatment in bed or immediate operation, but most of the patients are seen by a physician while they are still walking about, so that the symptoms should be fixed clearly in mind, ready for instant service. They vary according to the character of the compressed organ. Omentum may become strangulated and give only moderate pain and disability for days. Large intestine, and even small intestine if only a part of the circumference of the bowel is constricted, give the same symptoms in a more marked degree, plus vomiting and more or less distention. If the lumen of the small intestine is completely obstructed there is repeated vomiting, becoming brown and foul-smelling (“fecal”), and absolute stoppage of the bowels even for gas.

The various hernial orifices should be examined in all cases of intestinal obstruction.

Treatment – Dorsal decubitus, the steady pressure of a pad of unbleached cotton and a spica bandage, and the cold of a big ice-bag will cause the reduction of many strangulated hernias. This treatment should be tried only in the early hours of strangulation, lest one succeed in reducing a loop of intestine already gangrenous. In most cases immediate operation is indicated.

[Dorsal decubitus in this text means lying flat on ones’ back. I would most likely write an order: “Patient must remain supine and flat.”]

Kraske’s Operation (mentioned in the text description of photo) –involve the removal of the coccyx and excision of the left wing of the sacrum to afford approach for resection of the rectum in cases of cancer or stenosis.

No comments: