Hernia

There are several types of hernias, sometimes called ruptures, which arise from weaknesses in the abdominal wall. These out-pouchings of the abdominal (peritoneal) lining occur primarily in the groin, but are also found on the front wall of the abdomen and in the area of the diaphragm.

The typical groin hernia occurs from a congenital weakness in the structures comprising the inguinal ring. That is the connecting opening between the abdomen and the groin canal. The hernia first presents itself with a bulge in the groin. They frequently occur in infancy or early childhood.

Although some hernias may disappear, it is critical to have infant hernias evaluated. Usually they need prompt surgery to avoid complications. When an intestinal loop enters the hernia sac a bulging occurs, often associated with pain. If it is impossible to replace this protrusion within the abdominal cavity, the bowel is said to be incarcerated or trapped.

Prolonging this hazard may lead to strangulation, in which the blood supply is compromised. Unless prompt surgery is done, rupture or abdominal (peritoneal) infection may ensue. Hernias also occur in association with pregnancy, due to the increased abdominal pressure. Adult men may get hernias when they lift heavy objects, while subjecting the abdominal wall to sudden unusual strain.

With continued pressure, the hernia tends to enlarge. Mechanical support for a groin hernia with the truss may prevent further enlargement, but usually a surgical repair is indicated. Newer techniques involving one day in the hospital and the use of local anesthesia permit much more rapid convalescence.

They are the safer methods of surgery, being especially for the more stoical. Hernias that occur in previous incisions are called incisional or ventral hernias. Sometimes these result from infection, complicating previous surgery, where the wound has healed with residual weakness. Umbilical hernias are present in the navel.

They are frequently seen in newborns. The newborn or young child with an umbilical hernia needs so special care. Applying pressure or taping a quarter over the defect does no good at all. Unless the hernia is extremely large, however, it will gradually close, usually within one to two years.

Should it exist beyond the early period of infancy, surgical repair is indicated, primarily to avoid undue awareness to the area when your child enters school. Diaphragmatic hernias may occur congenitally, but are usually acquired during adult life. The most common is called a hiatus hernia.

It occurs when excessive food intake, obesity, tight-fitting garments, or undue straining produces a weakness in the diaphragm—the opening where the esophagus leaves the chest to connect with the stomach. Nearly half the cases treated surgically are unsuccessful, so medical therapy is usually advised.

This consists of a special diet, taking very little fluid intake with meals, and thoroughly chewing solid food. Lying down, bending over, or stooping after a meal is unwise. Supper should be a light meal, eaten several hours before going to bed. Tight-fitting belts and girdles are avoided.

If one experience nighttime heartburn, the head of the bed can be elevated on six inch blocks, allowing gravity to aid in preventing regurgitation of gastric contents during sleep. Persistence of symptoms such as pain or indigestion should be evaluated by a physician to determine the diagnosis. If necessary he can perform x-rays of the gastrointestinal tract.

Hemorrhoids

The veins of the rectum frequently become enlarged or tender, with sudden onset of brisk red bleeding. Called hemorrhoids, these annoyances are due primarily to our sedentary lifestyle, with the modern emphasis on refined foods containing little fiber. Sitting for prolonged periods or straining with bowel movements increases the venous pressure in the rectal area with the consequent development of these protruding veins.

External hemorrhoids are clusters of veins at the opening to the rectum (anus). They may develop a clot or thrombosis. These become excruciatingly painful and usually show an area of purplish or dark discoloration. Although gradual resolution will occur in 2-3 weeks with sitz baths, the most prompt relief is obtained by the incision of the thrombosed hemorrhoid, removing the offending clots.

This can be done with local anesthesia. Recurrence is uncommon. Treatment of the internal hemorrhoid, which more commonly bleeds and ulcerates, is usually conservative. Hot and cold sitz baths are given, described in the chapter on Hydrotherapy. In combination with a high fiber diet, they will usually allow the condition to subside.

At least two tablespoons of bran, with an abundance of fresh fruits and vegetables, are advisable to keep the stool soft. Aim at producing one or more substantial soft bowel movements daily. Surgical treatment of refractory hemorrhoid disease was formerly a very painful and costly procedure.

The development of the band ligation has changed this. A small rubber band is placed around the hemorrhoid high above the area of sensation, completely obliterating the hemorrhoid (varicosity). Two or three treatments in the office are necessary to complete this treatment. They are spaced at least three weeks apart to avoid excessive scarring.

Rectal suppositories provide some relief from the pain of hemorrhoid disease, and may be purchased over-the-counter at most pharmacies. However, complications such as prolapse of the rectum or malignancy may present. The final decision on hemorrhoids is best handled by a physician.

Appendicitis

As in many above conditions, appendicitis has been linked to the consumption of refined foods. Quite rare in rural Africans, this acute situation is seen most commonly in individuals obtaining little dietary roughage. The pain of appendicitis usually comes on suddenly, and is associated with nausea and vomiting.

A low grade fever develops, with rapid loss of appetite. The pain may at first be localized to the region of the stomach. It then migrates to the umbilicus, and finally localizes in the right lower quadrant of the abdomen. Deep pressure over the area will reveal a point of maximum tenderness.

Stand the person on his or her toes, and ask the person to drop suddenly on the heels. This usually aggravates the pain if the appendix or a related internal organ is inflamed. Usually there is no bleeding or diarrhea. Although some appendicitis cases can heal with simple measures, it is wise to obtain the counsel of a physician who can order the appropriate blood tests.

If his pain does not subside promptly, surgery is necessary. Rupture of the appendix is a serious complication. Intestinal contents laden with germs may then contaminate the abdominal cavity, raising fever, increasing the pain, and becoming life threatening unless surgical drainage is accomplished promptly. Mortality is much lower for appendicitis than it was in previous years, but prompt diagnosis and treatment are still necessary to save lives.

Gallstones

The high fat diet of this ‘junk food” age has rapidly increased the incidence of stone formation in the gallbladder. Designed to be a reservoir of bile, the gallbladder has the capability of concentrating this liquid into a thick syrup. A diet rich in fats and cholesterol tends to overcharge the bile with bile salts and cholesterol, which readily crystallizes to form stones.

Large single stones or many small stones may lie dormant for years, then produce a sudden crisis. In the area of the gallbladder, located just beneath the liver, pain develops, associated with vomiting, fever, or chills. When a gallstone passes into the common bile duct, obstruction occurs, with jaundice, and even more excruciating pain.

In such conditions surgery is mandatory to remove both the stones and diseased gallbladder. Nonsurgical treatment includes a low fat diet and strict avoidance of grease, oils, and other fatty foods. They may help the body to dissolve these stones.

Contrast x-rays and ultrasound tests can easily be done to evaluate the gallbladder’s progress. Check first to see if the patient is allergic to the iodine of the gallbladder dye. For best prevention I recommend steadfast control of obesity, and a lifetime adherence to natural foods. This will prevent most gallstones.

Peptic Ulcers

Usually ulcers involve the stomach or small intestine (duodenum) and can heal without surgery. The only conditions warranting surgery are severe gastrointestinal hemorrhage, or perforation of the ulcer with the spillage of stomach contents into the abdominal cavity. Also, the prolonged scarring of chronic ulcer disease can produce obstruction in the region of the stomach outlet (pylorus) or duodenum.

When this occurs and prolonged vomiting ensues, the only recourse is to surgically bypass the obstruction and again provide a basis for adequate nutrition. A fourth indication listed in many textbooks is intractability, meaning that the ulcer just won’t heal and therefore surgery is necessary. In my opinion, this usually implies that the patient is “intractable.”

Often a refusal to quit smoking, eliminate coffee or alcohol, or change behavior patterns to a more peaceful, low stress mode lies at the root of the nonhealing ulcer. In my medical and surgical experience, the best results in most types of ulcers are seen when the minimal amount of surgery is performed.

Usually this means a selective vagotomy, in which the small nerves that influence only the acid forming portion of the stomach are cut. When necessary, an operation to enlarge the pylorus or to bypass scarring is done. As all surgeons know, tampering with normal stomach physiology in this manner is not without hazard.

Iron deficiency anemia, the dumping syndrome (in which the ingestion of simple carbohydrates results in immediate diarrhea), abdominal cramps, and various types of malabsorption can occur. For the typical ulcer patient whose pain occurs shortly after eating or is aggravated by stress or harmful beverages, the remedy is logical.

Eliminate the offending substances—including spices, vinegar, tea, coffee, tobacco, alcohol, and fried foods. The recommended diet, although not entirely “bland,” allows considerable variety of food intake. If these foods are thoroughly masticated good results can be seen.

Avocado is an excellent source of dietary fat to inhibit gastric secretion. With adequate intake of soft fruits, olives, or creamed foods, prompt relief of pain, as well as neutralization of the acid can occur.

The intake of baking soda and use of aluminum containing antacids is discouraged, not only because of the cost, but also side effects elsewhere in the body. Hot packs over the abdomen and an abundance of cool water or diluted vegetable juices (carrot, cabbage, etc.) are also helpful in healing these common peptic conditions.

Varicose Veins

Tortuous dilation of surface veins in the lower extremities are also caused by our lifestyle. Prolonged standing and sitting allow an increase of venous pressure to develop in the lower extremities. Tight-fitting garments— such as girdles, belts and garters—will predispose to this degenerative condition.

The increased venous pressure of late pregnancy often aggravates the situation. Elastic stockings are very helpful to prevent throbbing and progressive dilation of these large leg veins.

Surgical treatment may be necessary, with the ligation and stripping of the veins, but this should be evaluated by an experienced surgeon competent to assess the indications—one who is inclined to avoid surgery whenever possible.

Proper posture, daily exercise, deep breathing, and a diet that maintains good bowel action will all assist to keep the pressure low in the veins and thereby prevent unsightly legs, throbbing calves, or the ulcers that occasionally follow.

Tonsillectomy

Formerly the most common operation in the United States, tonsillectomy has fortunately declined in popularity. It is now known that our tonsils play a useful role in the formation of antibodies to respiratory infections. The incidence of poliomyelitis and cancer have been less in those fortunate individuals who were able to keep their tonsils.

Infections in these organs will usually respond to prompt administration of simple remedies. Indications for surgical removal of the tonsils are primarily limited to chronic recurring infections where the deep pockets (crypts) prevent adequate self-cleansing, and debris and infected material reside there.

Recurring ear infections sometimes require the related lymph tissues in the nasal pharynx, called adenoids, to be removed. Both of these operations should be highly selective.

Coronary Bypass

Although the complexities of coronary bypass surgery are beyond the scope of this book, a few comments are in order. Briefly stated, this recent surgical advance is a procedure involving the removal of one or both of the major veins (saphenous vein) in the leg and its careful transplantation in the chest.

After appropriate cardiac catheterization to determine the adequacy of the coronary circulation, the vein is placed between a hole made in the aorta as it leaves the heart and the more distant part of the coronary artery. With its 5-10% risk to life, the exorbitant cost ($30-50 thousand), and the lack of long-term statistics as to its effectiveness (at best 2 years), this operation should be regarded as a last resort.

Reconditioning programs are springing up around the country and offering a superior alternative to many bypass candidates. The combination of a low fat diet free of cholesterol and progressive exercise in a center with preventive capabilities will often minimize the necessity for cardiac drugs, while relieving chest pain and similar cardiac symptoms.

Nevertheless, a few individuals with disease of all three coronary vessels or underlying impairment of the heart valves may need and profit from this operation. In such cases, it is my recommendation that a medical center experienced in heart surgery be selected with much prayer and care.

Following the bypass operation, cardiac rehabilitation should begin in a lifestyle conditioning center where both diet and lectures are calculated to prevent recurrence. As rapidly as possible this will recondition the patient for a return to normal living.

Otherwise, the temporary relief obtained by a revascularization procedure may be short-lived as the new vessels plug themselves with cholesterol once again. One can easily see how every aspect of coronary heart disease from the cradle to the rocking chair will benefit from preventive measures.