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A stitch in time saves nine.

“DOCTOR AT SEA” a monthly Column in The Islander Magazine

A stitch in time saves nine.

A stitch in time saving nine is an old proverb intended to encourage prompt action rather than neglect and inaction. A small hernia can become a big hernia if left untreated and a big hernia can lead to complications which could be life-threatening and even more so if allowed to develop at sea.

My impression, especially amongst younger adults attending for an ENG1 medical or enrolled on our courses, is that a significant number do not know what a hernia is so hopefully a few explanatory comments will help.

A hernia occurs when there is a break in supporting structures, usually abdominal muscles, and a piece of bowel pokes through forming a soft lump under the skin on the surface. The abdominal cavity is bordered by the dome of the diaphragm above, the spine and rib cage behind, the pelvis below and a strong muscular wall to the front and sides. The grain of these muscles of the abdominal wall run in three different directions, the vertical grain runs in the front pair which form the basis of the cherished six-pack. The grain of the muscles is just like the grain seen in a good piece of steak which is also an example of muscle. Occasionally the fibres of this grain split apart under increased pressure such as experienced with heavy lifting, frequent constipation or chronic coughing and then a hernia is born!

The commonest hernias occur in the groins and can also occur in babies due to an inherent weakness in that area which allows bowel to tunnel through to form a soft lump without the increased pressure normally required. Another weak spot is around the umbilicus and hernias can also form at the site of surgical incisions which have not healed fully,

These various hernias are relatively benign problems and can sometimes be eased back manually behind the muscle wall and back into place. They feel soft and there is a definite surge of pressure felt at the lump when coughing – this is called a cough impulse. If the lump gets bigger, as the segment of bowel poking out gets longer, there is a risk that the segment will twist on itself rather like a sausage balloon used in party decorations. This is very serious – the hernia is now strangulated and the tight twist stops the blood supply thereby risking tissue death and gangrene.The lump is now hard and painful and it is isolated from the rest of the bowel by the twist so there is no cough impulse. A strangulated hernia is a surgical emergency and it is for this reason that ENG1 guidelines are clear about treating hernias early – “a stitch in time saves nine”.

These abdominal wall hernias are visible and, as a group, form what we normally refer to as hernias but there are several internal, and therefore invisible, defects which can lead to structures poking through abnormally and causing symptoms. The two which crop up most frequently in feedback in our courses are hiatus hernia and herniated intervertebral discs.

A hiatus hernia forms when the lower end of the gullet is loose at the attachment to the upper part (hiatus) of the stomach. This looseness allows the stomach to herniate upwards and to allow stomach acid to enter the lower part of the gullet producing heartburn, made worse when lying down or bending forward which encourages acid entry into the gullet. There are now specific and very effective medications available to treat this condition.

Intervertebral discs are very firm cushions between the bony vertebral bodies of the spine. These discs have a soft viscous centre which produces some flexibility and cushioning but if pressure is applied to the spine when it is flexed forwards, as in very inefficient heavy lifting with the back bent rather than legs bent and the back straight, then a portion of this softer centre can squirt backwards and herniate towards the nerves coming out from the spinal cord. The pressure of this hernia of disc material can cause severe pain along the path of whichever nerve root is affected but is commonly the sciatic nerve which runs down the back of the leg. Sciatic pain from a herniated “slipped” disc can be disabling and nerve root compression can become an emergency if bladder function or leg function becomes affected.

Symptoms which interfere significantly with everyday life can lead to some restrictions on duties at sea but most people with a prolapsed intervertebral disc (“slipped disc”) have learned to live with the symptoms and know how to avoid aggravating their condition.

So hernias, both external and internal, can be treated especially if dealt with early and particularly the external ones which can strangulate and kill. We had one lucky student who had a strangulated hernia days out at sea and it untwisted spontaneously – but much better to get a stitch in time!

Dr Ken Prudhoe, MCA Approved Doctor, can be contacted at Club de Mar Medical Centre, Palma de Mallorca.

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