HERNIA (a Latin term commonly derived from Ipvos, a sprout, but this origin is doubtful) is the protrusion of any viscus from its normal cavity; for example, hernia cerebri is the name given to a protrusion of the brain substance, hernia pulmonum a protrusion of a portion of the lung. The word may here be restricted to its most usual meaning, a protrusion of part of the contents of the abdomen from their normal position in the abdominal cavity,—in common language a "rupture." A rupture may occur at any weak point in the abdominal wall. The common situations are the groin (inguinal herria), the upper part of the thigh (femoral hernia), and the umbilicus or navel (umbilical hernia). The contents of a rupture may be any of the abdominal viscera; the more movable the viscus the more tendency there is to protrusion, and therefore we generally find that the small intestine and the omentum are most frequently displaced. The tumour may contain intestine alone (enterocele), omentum alone (epiplocele), or a combination of intestine and omentum (entero-epiplocele). The predisposing cause to rupture is any weakness of the abdominal wall due (1) to natural conformity, as in inguinal hernia, which descends along the inguinal canal, a canal in which the cord lies in the male and the round ligament in the female; or in femoral hernia, in which the hernia descends along the femoral canal along with and to the inner side of the femoral vessels; (2) to any cause which weakens the wall locally, as an abscess or wound; (3) to general laxity of the tissues, as in weakly people, or after repeated pregnancies. This third cause only predisposes to hernia in so far as it may weaken an already weak part under the first and second heads. The exciting cause of hernia is generally some strain or over-exertion in any powerful effort, as lifting a heavy weight, jumping off a high wall, straining, as in difficult micturition or in conse-quence of constipation, or excessive coughing, as in chronic bronchitis. The pressure of the diaphragm above and the anterior abdominal wall in front acting on the abdominal viscera tends to cause their 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, the result of one or other of the accidents referred to above. Ruptures are most frequent at the extremes of life. Men suffer more frequently than women, because they are more liable to those accidents, being frequently exposed to intermittent work, such as the lifting of heavy weights.

At first the rupture is small, and with more or less rapidity it gradually increases in size; it varies from the size of a small marble to that of a child's head or even larger. The swelling which appears is spoken of as con-sisting of three parts,—the coverings, sac, and contents.

(1) The "coverings" are composed of the different structures which form the abdominal wall at the part where the rupture occurs. In femoral hernia the coverings are formed of the structures at the upper part of the thigh. These structures are stretched and may be thinned; in some cases they are condensed and matted together, the result of pressure; in others there is an increase in their thickness, the result of repeated attacks of inflammation.

(2) The " sac" is composed of the peritoneum or mem-brane lining the abdominal cavity; in some very rare cases the sac is wanting. The neck of the sac is the term used to designate the narrowed portion where the peri-toneum forming the sac becomes continuous with the general peritonea] cavity. Very frequently the neck of the sac is thickened, indurated, and adherent to surround-ing parts, because here the tendency to local inflammatory action is most marked, the pressure being greatest at this point. (3) The " contents " have already been described. There are three distinct conditions in which we may find the contents of a hernial tumour: it may be either reducible, irreducible, or strangulated. A "reducible" hernia is one in which the contents can be pushed back into the abdomen. In some cases this is done with ease, in others it is a matter of great difficulty. At any moment a reducible hernia may become "irreducible," that is to say, its contents cannot be pushed back into the abdominal cavity. This may f.uddenly occur in conse-quence of an attack of constipation, or slowly, the irreduci-bility being at first partial and gradually becoming more and more complete. Generally this is due to an increase in the size of the omentum, accompanied by inflammatory induration. A " strangulated " hernia is one in which the circulation of the blood through the hernial contents is interfered with. The interference is at first slight, but very rapidly tends to become more pronounced. At first there is congestion ; this congestion may go on to inflam-mation ; if unrelieved, the inflammation will end in morti-fication. The rapidity with which the change from simple congestion to mortification takes place will depend on the tightness of the constricting cause; as a rule the more rapidly a hernia forms, in other words, the less time the surrounding tissues have to accommodate themselves to the protruding swelling, the greater the rapidity of the changes in the conditions >.f the contents. The constricting agent may be one or other of the structures which form the boundaries of the openings through which the hernia has travelled in its gradual course through the abdominal wall, or it may lie in the neck of the sac, which has become thickened in consequence of inflammation.





Reducible Hernia.—The symptoms of reducible hernia show themselves in a soft compressible tumour (elastic when it contains intestine, doughy when it contains omentum, a combination of elasticity and doughiness when both are present), its size increasing in the erect, and diminishing in the horizontal posture, whence as a rule it gives little trouble during the night, and becomes more troublesome in the daytime, more especially towards evening. There is a more or less distinct 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 situa-tions are—(a) 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 anterior superior spinous proeess of the ilium to the spine of the pubis immediately above the genital organs); (b) 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; (c) the umbilical region, in which the tumour appears at the navel. As the inguinal hernia increases in size it tends to pass into the scrotum in the male, into the labium in the female ; while the femoral hernia, appearing first below Poupart, tends gradually as it increases in size to pass upwards superficial to Poupart's ligament.

The treatment of reducible hernia consists in pushing back the contents of the tumour into the abdomen, and applying a truss or elastic bandage in order to prevent the contents from again escap-ing. The younger the patient the more chance there is of the truss acting as a curative agent, as the natural tendency to contraction of the channel through which the hernia protrudes is greater. The truss is frequently laid aside at night, because in the horizontal posture the tendency of the contents to descend is greatly lessened. The truss or bandage should, however, be worn day and night. If, after the hernia is once returned, it is never again allowed to come down, there is a probability of a 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 turning suddenly in bed, the parts are stretched, and the contracting process which may have been going on for weeks is undone.

It is unnecessary to describe the multitudinous varieties of trusses. When a truss is ordered the surgeon has to see that it fits accurately, the necessary amount of pressure being obtained by means of a steel spring, to which a pad is attached. The pad should be so arranged as to press, not into the opening through which the hernia has come, but rather on its sides, so as to facili-tate its contraction and permanent closure. The main pressure should be in the neighbourhood of the neck of the sac; if the pad presses into the opening, the tendency is to keep the opening patent. The principle of the nipple-shaped pad, frequently ordered for umbilical hernia, is evil; a flat pad properly applied and held in position by an elastic bandage is the proper arrangement for restraining an umbilical hernia. No truss is to be applied until the hernia is completely reduced; it will only do harm by pressing on the contents of the unreduced hernia. In some hernias, gene-rally those of large size, it is found impossible to keep them up by means of a truss; in such cases an elastic bandage will sometimes effect the object, in others various operations have been recom-mended. They are spoken of as " the radical cure of hernia," in contradistinction to the so-called " palliative treatment by means of a truss." An attempt has been made above to show that a truss may radically cure a hernia. The principles involved in the operations described are (1) obliteration of the neck of the sac, (2) obliteration'of the channel through which the hernia has de-scended, (3) obliteration of the sac itself, (4) plugging of the channel by invaginating the loose skin. The first and second are specially important, as in them the surgeon imitates nature's way of attempting to cure the tendency to hernial protrusion.





Irreducible Hernia.—Here the main symptom is a tumour in one or other of the situations already referred to, of long standing and generally 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 in the contents, cither 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 tendency to increase in size; it may at any time become strangulated, or the contents may inflame, and strangula-tion may occur secondarily to the inflammation. It is accompanied by dragging sensations referred to the abdomen, colic, dyspepsia, and constipation, which may in its turn lead to obstruction, that is to say, a stoppage of the passage of the contents of that portion of the intestinal canal which lies in the hernial tumour. "When an irreducible hernia becomes painful and tender, a local peritonitis has occurred, which resembles in many of its symptoms a case of strangulation.

The treatment of irreducible hernia may be palliative: a bag truss may be worn to prevent the swelling from 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 more than palliation is called for. An attempt should be made to reduce the hernia—(1) by laying the patient on his back, raising his buttocks, administering purgatives, and starving him (persevering attention to these points may so reduce the size of the contents that the hernia may be re-turned) ; or (2) by means of an elastic bandage carefully applied so as to press continuously on the tumour, and gradually press it back into the abdominal cavity. By this simple means large irreducible hernia?, which have withstood all attempts at reduction, have been returned into the abdomen after elastic pressure has been carefully and continuously applied for a few days. (3) The surgeon may cut down on the hernia, under strict antiseptic precautions, open the sac, divide any omental adhesions, ligature and cut away in-durated omentum, return the bowel, and then tie the neck of the sac. Such an operation is unjustifiable unless other means have been fairly tried and failed, and unless the hernia is giving rise to such symptoms that the usefulness of the patient is interfered with.

Strangulated Hernia.—In this the contents are constricted, and the flow of blood into the tumour and from the tumour is stopped. The symptoms are—nausea, vomiting first of bilious matter, after a time of faecal matter, a twisting, burning pain generally referred to the umbilicus, intestinal obstruction, a quick wiry pulse, pain on pressure over the tumour and in the abdomen near the tumour, the abdomen tense and tympanitic, and no impulse on coughing, because the contents of the tumour are practically cut off from the general abdominal contents. The patient has an anxious expres-sion. Sooner or later, from eight hours to eight days, if the strangulation is unrelieved, the tumour will become livid and em-physematous; mortification has occurred, and gangrene of the bowel at the neck of the sac will take place, followed by extrava-sation of the intestinal contents into the abdominal cavity ; the patient becomes collapsed, and dies comatose.

The treatment of a strangulated hernia admits of no delay; delay is fatal. If the symptoms are not very acute, and if the case is seen early, attempts may be made by large enemata and by the application of cold to the tumour to reduce the congested condition and relieve the strangulation. But these attempts must not be persevered with for more than two or three hours. If the strangulation continues, then the patient should be told that his case is one which admits of no delay. Chloroform should be administered; another attempt to return the contents by pressure (termed "the taxis") should be made. If this has already been fairly tried, and if the symptoms indicate urgency, no prolonged attempts at taxis are justifiable, because the condition of the hernial contents may be such that they cannot bear the pressure. 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, out-wards, and backwards, the femoral hernia downwards, backwards, and upwards. The larger the hernia the greater is the chance of success. The slightest gurgle indicates that success is near. If taxis does not succeed then the surgeon must 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 condition of the bowel is then examined, and. if it is glistening, however black it may be, it is returned into the abdomen. If it has lost its glistening aspect, if it is like "wet parchment," then the case is very doubt ful. If in doubt, relieve the constriction and leave the bowel in the sac. Never open the bowel, however bad it looks; it may recover,-and if it does not burst for some hours afterwards, the chances are that adhesions may form at the neck of the sac and lessen the risk of extravasation into the abdominal cavity—a faecal fistula will be the result. The omentum, if healthy, may be returned; or if congested and indurated, it may be ligatured and cut off. After the bowel is returned the wound is sewn up, and a pad and flannel bandage applied. A dose of opium should be given to prevent movement of the bowels. On the third day a dose of castor oil is administered if the bowels do not open naturally. A truss is applied after the wound is healed before the patient is allowed to get out of bed. Many complications which may occur cannot here be referred to. Any one suffering from hernia should take great care to obtain an accurately fitting truss, and should remember that, whenever any synvptoms resembling in any degree those of strangulation occur, any delay in the treatment is not only dangerous but may prove fatal. A medical man should at once be communicated with. He in his turn has to remember that when a patient asks his advice, complaining of symptoms resembling strangulation, he must examine all the situations where hernia may occur, because the hernial tumour may bo so small that it has escaped the notice of the patient. Any assertion on the patient's part that he does not suffer from hernia must receive no weight. The surgeon must satisfy himself by ocular inspection and manual examination. If an operation is necessary he may with confidence say that the operation is not in itself a dangerous one, while, on the other hand, he can assure the patient that any delay is most certainly excessively dangerous. (J. C.)