Hernias in Austere Circumstances

You know, we are so aware of our bodies.  Every little change.  Every zit, mole, age spot, gray hair.  We don’t necessarily like them, but even if they happen suddenly, we accept these little things as normal parts of the ageing process. 

Then there are those sudden changes that set off alarms.  One minute the skin covering your abdomen is nice and smooth; the next, you find yourself with a cute little bulge.  A brand spanking new baby hernia. Congratulations.

In most of us, any new bulges of what was previously inside working towards the outside are going to cause some mental anguish.  Especially in an austere situation where professional care is limited or non-existent.  And with the way things are progressing in the US, it feels as if competent, prompt care is becoming further out of reach—limited to non-existent.

So what exactly is a hernia, what can we do to prevent it, and if prevention fails, what can we do to treat it?

Let’s begin with the following information from The Ship’s Medicine Chest, a US government publication.  It contains a true treasure trove of practical knowledge essential to seamen at a time when medical emergencies had to be handled by untrained personnel with limited access to medical supplies.  Like may occur when we find ourselves in austere circumstances. 

Hernia (Rupture)

A hernia is a protrusion of an organ or a part of the intestine through a wall of the cavity in which it is normally enclosed.  Ordinarily, a hernia means the protrusion of the intestine through a weak place in the abdominal wall.

Treatment

The patient should be placed on his back with hips higher than the shoulders.  The knees should be drawn up to relax the abdominal muscles.  Then, by gentle manipulation with the fingers, a gradual effort should be made to work the sac back into the abdomen.  If a rupture has been protruding for a long time, adhesions may have formed and may prevent its reduction.

To reduce the more difficult hernias, morphine sulfate 10 mg should be given intramuscularly to relax the abdominal musculature and to relieve pain.  About 45 minutes after giving this medication, an attempt should be made to reduce the hernia.  Once the hernia has been reduced, the patient should be kept at bed rest on a liquid diet and given milk of magnesia to prevent constipation.  Before repeating the morphine sulfate, medical advice by radio should be obtained.

When the rupture cannot be reduced, the protruding intestine may become compressed by adhesions or swelling to such a degree that its blood supply is shut off.  This strangulated hernia is very serious.  Symptoms are similar to those of obstruction of the bowel (see p. 163).  Gangrene of the bowel may cause general peritonitis and death within a few days unless properly treated.  Medical advice by radio should be obtained promptly.[1]

So that’s the basic info from The Ship’s Medicine Chest.  After reading that, you probably have a lot of questions.  I know I did. 

Types of hernias

There are actually several types of hernias.  The uncommon ones that can be difficult for even trained professionals to identify or that are rare will not be addressed.

• Inguinal.  This hernia into the groin is the most common in both men and women; however, it is about ten times more likely to occur in men.  In males, it occurs when an opening in the abdominal wall from the passage of the testicle into the scrotum does not close normally before birth or reopens later in life.  In women, this canal contains the round ligament (the area that surrounds and supports the uterus) and is much smaller but still exists and can reopen later in life.[2]
• Umbilical.  As an unborn baby develops, there is a hole in the abdominal wall where the umbilical cord passes between the baby and the mother.  After birth this opening closes but remains an area of weakness in the abdominal wall.  Over time and with strain, this area of weakness can reopen, permitting a loop of the intestine to bulge out into a hernia.[3]
• Femoral.  This hernia occurs as a bulge near the groin or thigh.  It is not common, less than 5% of all hernias.  It most frequently is found in elderly, thin females.[4]
• Epigastric.  Between the belly button and the breastbone is a natural area of weakness where fat or intestine can bulge through the abdominal wall.
• Hiatal.  This hernia occurs when the diaphragm, the large flat muscle that separates the abdomen from the chest, stretches and allows the stomach to bulge up from the abdomen through the diaphragm and into the chest.  Many people don’t feel any symptoms at all; in others, heartburn is a common sign of hiatal hernia.  Unlike the other hernias being covered today, there will be no visible bulges on the body surface.
• Incisional.  This hernia occurs months to years after surgery in the area of the scar.

Risk factors

Anything that strains the abdominal wall may predispose a person to developing a hernia. This includes:

• Heavy lifting[5]
• Chronic coughing due to asthma, bronchitis, COPD, smoking, acid reflux, etc. increases the risk of inguinal hernia. [6]
• Chronic constipation[7]
• Abdominal weight gain[8]
• Pregnancy[9]
• Surgery[10]
• Genetics/family history[11] [12]
• Being white[13]
• Being older[14]

Prevention

While one can’t do anything about gender, sex, race, or age, avoiding heavy lifting as we age is a good idea.  So are all the other standard answers—maintain a healthy weight, eat lots of fruits and vegetables—high fiber diet, and quit smoking.

Treatment

Beyond the discomfort, the primary concern with a hernia is the possible strangulation of the intestines within the hernia sac.  If the blood supply to the entrapped intestines is cut off, death of the intestines will occur, and without surgery in this case, death of the patient as well.  Fortunately, this is a rare occurrence.  However, if a patient’s life is at stake, simple surgery either to correct the defect or enlarge it (and thus lessen the risk of strangulation) may be performed by a veterinarian, surgical tech, operating room nurse, or physician’s assistant.[15]

If the patient has a hernia that seems trapped, here are the steps to try to reduce it:

• Lay the patient flat on his back.  If the hernia is in the groin, elevate the foot of the bed to about 20°. 
• Apply a cool compress or ice to the affected area to reduce swelling.
• Allow 30 minutes to see if the hernia will reduce on its own. 
• If not, apply steady, gentle pressure to the bulge and guide it back through the opening. 
• If at first you don’t succeed, try, try again.

Most patients never suffer a significant problem from an uncorrected hernia.  Some wear abdominal binders to prevent the hernia from bulging out.  If you do not have a commercially manufactured one (they’re available on Amazon), you’ll want to have the supplies to make your own should the need arise.

Links to related posts:

The Ship’s Medicine Chest and Medical Aid at Sea  

References:

https://www.stamfordhealth.org/healthflash-blog/surgery/hernia-types-risk-factors/

https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

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[1] The Ship’s Medicine Chest and Medical Aid at Sea, 1978, 167-68.

[2] https://www.stamfordhealth.org/healthflash-blog/surgery/hernia-types-risk-factors/

[3] https://www.stamfordhealth.org/healthflash-blog/surgery/hernia-types-risk-factors/

[4] https://www.stamfordhealth.org/healthflash-blog/surgery/hernia-types-risk-factors/

[5] https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

[6] https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

[7] https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

[8] https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

[9] https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

[10] https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

[11] https://www.stamfordhealth.org/healthflash-blog/surgery/hernia-types-risk-factors/

[12] https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

[13] https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

[14] https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

[15] Cynthia Koelker, Armageddon Medicine, 369.