still go on and die very rapidly of septicemia, peritonitis, septic pneumonia,
and exhaustion. The mortality of untreated cases of strangulated hernia is
at least ninety-five per cent. As already indicated, some of the patients die in
a condition of collapse during the first day ; others, after two or three or more
days, of exhaustion ; others of peritonitis ; others as the result of the rupture of
the gut and septic phlegmonous inflammation of the scrotum, abdominal wall,
and thighs ; still others of pneumonia ; and among those where an artificial
anus spontaneously forms, especially if it be in the small intestine, some will
die of inanition after weeks or months.
Local Symptoms and Changes in the Rupture Itself. — The strangulated
hernia becomes larger, -more tense, and firmer, and is extremely painful on
pressure, there being always a point of fixed pain, most intense in the neigh-
borhood of the neck of the sac. The hernia becomes at once irreducible ; there
is no impulse upon coughing, nor do any of the other causes, such as vomit-
ing, straining, and the like, produce any change in the tension of the hernial
mass. Upon percussion the hernial tumor may be flat, dull, or tympanitic.
The chief diagnostic value of irreducibility in strangulated hernia is observed
in those cases formerly reducible, which suddenly become irreducible, with
the symptoms of pain, general and local, and localized tenderness. It is to be
borne in mind that among the aged both the local and general symptoms may
be much less marked. The local pain and tenderness may be slight, and if
the hernial tumor be very small, it may escape observation altogether. The
patients sink into an indolent and apathetic state with gradually increas-
ing symptoms of exhaustion and final collapse. If the intestine ruptures into
CLINICAL VARIETIES OF HERNIA 273
tlie sac, the overlying sofl parte rapidly become swollen, red, edematous, and
crepitanl on palpation; one or more 3pots, al firsl of a dark red or mahogany
color, are observed upon the skin, and these become gangrenous and softened,
the abscess finally rupturing ;it one or several points. The onsel of peritonitis
from perforation into the abdominal cavity or the spread of infection from the
hernial sac does no1 differ in its general and local 3igns from those already
described under Diffuse Peritonitis. Among the fatal complications are pneu-
monia, usually of the septic lobular type, sometimes pyemic from the lodgment
of -null emboli from the mesenteric vessels. Suppression of urine is nol infre-
quenl in the aged, and in all cases of strangulated hernia the amount of urine
excreted is uotably diminished.
Diagnosis of Strangulated Hernia. — In the majority of cases of strangu-
lated hernia the presence of a hernial tumor, which suddenly becomes irre-
ducible with the typical symptoms already described, presents no diagn
difficulties. Still, atypical cases occur, and many ^ood surgeons have made
grievous errors in diagnosis. The risk of falsely assuming thai a hernia is
not strangulated is, of course, a far greater peril for the patient than is the
assumption that a hernia is strangulated when it is not; the latter error rarely
doing any serious harm, the former will probably cost the patient his life.
The besl means of avoiding error is a careful and thorough examination. It
is to be home in mind that two or more hernia' may exist at the same time,
and that one of them may he strangulated, and thai thai one may he so small
as to escape observation. 77 is there fun- highly important when a patient is
suddenly seized with symptoms indicating strangulation of the bowel to exam-
ine with core no/ only the ordinary sites of hernia, but also the unusual sites.
In cases of very small hernia', and notably those in unusual situations, it
may not be possible to deteel a tumor, bul merely an increased sense of resist-
ance and a tixed point of pain and tenderness. The signs derived from percus-
sion are no1 of greal diagnostic value. The hernia may be empty at the time
it becomes strangulated, or at leasl contain no gas. Under these circumstances
it will he dull or flat upon percussion. The tympanitic note may be covered
up by the serous exudate in the hernial sac. In certain types of strangulated
hernia the characteristic symptoms may he masked or modified. The following
classes of cases of this character are quoted from Blake:
T. Cases in which the peculiarities are dependent upon the content- of
tin' sac.
A. Strangulation of a portion of the bowel.
{a) Partial enterocele ( Etichter's hernia').
(b) Strangulation of the vermiform appendix.
(c) Strangulation of Meckel's diverticulum (Littre's hernia).
B. Strangulation within the body of the sac.
(a) By bands, adhesions, apertures in omentum, etc.
(b) \W kinks or volvulus.
274 HERNIA
II. Cases in which the peculiarities are dependent upon the sac.
(a) Strangulation within a loculus or pouch of the sac.
A. Strangulation of a Portion of the Bowel. — (a) In these eases the hernia
is always small, and has a narrow rigid orifice. It is rarely seen in inguinal
hernia, is fairly common in femoral hernia, and has been observed in obturator
hernia. There is seldom a definite history of the former presence of hernia,
and the attack comes on suddenly as the result of one of the types of muscu-
lar effort already indicated. It sometimes happens that the symptoms of
intestinal obstruction are absent or not marked, while the local symptoms are
quite characteristic. Nevertheless, at the very beginning the patient may ex-
hibit very distinctly the evidences of abdominal shock. Not operated upon,
these partial hernias almost invariably end in gangrene of the gut. The intes-
tine forms the sole contents of the hernial sac, and upon operation a lateral
pouch or projection of the wall of the intestine is discovered in a strangulated
condition, and frequently so drawn out as to resemble a diverticulum, (b) No
characteristic signs and symptoms can be given to indicate the presence of a
strangulated hernia of the vermiform appendix other than the local signs
of a small hernia, painful and tender on palpation and without the symptoms
of intestinal obstruction until such time as peritonitis has developed. II. (a)
In cases where a portion of a hernia becomes strangulated in a lateral pouch
of a hernial sac the general symptoms will be the usual ones. There will be
localized pain and tenderness in the hernia, but a portion of it may still be
reducible. There may be gurgling and tympanitic resonance on percussion.
Strangulation of the Omentum Alone.— The omentum may become strangu-
lated when it is suddenly forced through a hernial aperture by violent muscular
contraction, and is subsequently pinched by the hernial ring; or when by a
similar mechanism an additional portion of omentum descends into a hernial
sac already occupied by a part of the same structure. The strangulation gives
rise to disturbances of circulation, swelling, thrombosis of the vessels of the
omentum, sometimes to gangrene and suppurative inflammation in the sac.
The production of gangrene in the omentum is usually a much slower process
than is the case with the intestine. The symptoms are very much less severe
than in strangulated hernia of the gut. There is localized pain and tender-
ness, abdominal pain, sometimes referred to the epigastrium ; the hernial tumor
is flat upon percussion ; it becomes larger and harder. It is usually possible
to feel the indurated nodular masses of omentum in the sac quite different
from the rounded, smooth, tense, and elastic quality of intestine. Although
these patients vomit, the bowels continue to move, and they do not pass into
a condition of shock. After the symptoms have existed for a number of days
the process may end in resolution, after which the omentum will no longer be
reducible, from causes already described. If gangrene or suppuration occurs,
a relatively rare happening, there will be the development of a phlegmonous
inflammation of the sac and overlying soft parts, giving the characteristic signs
CLINICAL YAKII.TIKK OF IIKK.MA 275
and symptoms of this condition as elsewhere described. A spread of the septic
process to the peritoneum and peritonitis is possible. In :i fev cases only the
general symptoms have been severe and marked from tin- start, resembling those
of si rangulal i«>n of the gut.
Certain other groups of cases and conditions may be mentioned as leading
to possible errors of diagnosis, as enumerated by Eccles:
1. Cases with multiple hernia, one irreducible, the other strangulated.
2. Two hernia?, one covering up or concealing the other.
-'!. An inguinal and a femora] hernia on the same side; one strangulated,
the oilier not.
•1. Cases with an irreducible hernia in which the obstruction or strangula-
tion has occurred inside the belly, and not in the hernia itself.
The differential diagnosis between strangulated hernia and other special
conditions will he spoken id' when describing special forms of hernia. A few
words in regard to the choice of treatment in strangulated hernia may not be
out <»f place.
Treatment. — In a general way it may he said that the reduction of strangu-
lated hernia by taxis is no lunger regarded as the safest method of treatment.
Thai is to say, there are certain very serious risks attending its use not involved
in a cutting operation. Taxis may be tried in cases: (1) Where the general
and local symptoms are slight. (2) Where the hernial ring is very large, and
where the hernia was formerly reducible, or has been strangulated before and
reduced by taxis. (3) Cases in which there are marked general contraindica-
tions and difficulties in the operation, such as are found in feeble old people
with large hernia 1 . (4) In young infants. (5) When, the hernia having been
formerly reducible, the surgeon is called very soon, within an hour or two,
after strangulation has taken place. Taxis is contraindicated : (1) When it has
already been tried. ('2) When the symptoms have come on suddenly and
severely, notably in very small hernia' in which strangulation has existed for
so many hours that the gut is probably gangrenous. The limit is ordinarily
placed at twenty-four hours. This period would appear to me to be too long.
(3) In all cases where the hernia lias been previously irreducible. The dan-
gers of taxis are: (1) The rupture of an already friable or gangrenous intes-
tine. (2) The forcing of an intestine back into the abdomen, where it subse-
quently ruptures and produces peritonitis. (3) The transference of infected
fluid in the hernial sac into the abdominal cavity. (4) Reduction en m
( 5 ) Tvupture of the mesentery with serious hemorrhage into the abdominal
cavity. (0) Rupture of the sac, so that its contents are forced into the sur-
rounding tissues. By reduction en masse, or apparent reduction, is meant that
the sac, together with its contents, are forced through the hernial canal and
come to lie between the transversalis fascia and the anterior abdominal wall,
producing a form of interstitial hernia, while the neck of the sac still remains
as a constricting band about the intestine. The sac and its contents may also
be forced back into the free abdominal cavity, where they may remain >till
276 HERKIA
strangulated. Other possibilities are that the sac ruptures near its neck, and
its contents are forced into the retroperitoneal tissues, or that the parietal peri-
toneum and the sac as well rupture along circular lines, leaving the constricted
neck still surrounding the intestine.
Taxis is known to have been successful when the tumor disappears with a
gurgling sound into the interior of the abdomen, and its former site is entirely
emptied. It is usually possible for the surgeon to follow the hernial canal to
and through the hernial ring after reduction is complete. A further and most
important sign of success is the speedy relief of the symptoms of strangulation
and a normal movement of the bowels. Should the surgeon decide to employ
taxis he will use the utmost gentleness in his manipulations. His efforts
should not be continued more than three or four minutes. He should be
ready to operate at once if the taxis fails. At the present time surgeons are
in the habit of treating cases of strangulated hernia by an open operation in
all but very exceptional cases. In regard to the operative treatment of strangu-
lated hernia, it may be said that if the patient's condition is very feeble local
anesthesia should be employed, if possible. The incision should be liberal
through the skin. The constricting band should be divided from without
inward rather than in the opposite direction ; a liberal exposure of the sac and
its contents should be made, so that all the work may be done under the control
of the eye. After the division of the constriction the surgeon determines the
condition of the strangulated intestine by the rules already indicated. Should
the gut be in such condition as to permit returning it to the abdomen one or
other of the radical operations for hernia is performed, according to the ana-
tomical site. Should the gut be gangrenous, immediate resection of the intes-
tine gives better results than the formation of an artificial anus. Thus, Gibson,
1900 (Annals of Surgery), found that in 101 cases where an artificial anus
was formed there were 53 deaths, a mortality of 52.5 per cent. In 226 cases
where primary resection and reunion of the intestine was made at the time
there were 58 deaths, a mortality of 26 per cent. The large number of deaths
following the formation of an artificial anus are due not only to the conditions
present at the time of operation, but also to the large number of deaths which
occur from inanition when the gangrene affects the middle or upper portion
of the small intestine, and further to the dangers accompanying the operative
measures for the subsequent closure of the artificial anus. When the gut is
found to be gangrenous the incision through the abdominal wall should be
liberal, so that the surgeon may inspect thoroughly the intestines still within
the abdomen. Resection should be done at a point removed some little dis-
tance on either side from that portion of intestine whose nutrition is visibly
impaired. The decision on the part of the surgeon as to whether he will
make an artificial anus or do a primary resection will also depend to some
extent upon his personal skill and experience in intestinal surgery.
SPECIAL FORMS OF HERNIA
SPECIAL FORMS OF HERNIA
Inguinal Hernia. — By inguinal hernia we understand those forms of her
nial protrusion which pass into or through the inguinal canal, i For the detailed
anatomy of the inguinal canal the reader is referred to works on anatomy and
i<. larger works on general surgery, i A few details are necessarily given here
in order thai the various forms of hernia in this region may be understood.
In the early months of fetal life a pouch or process of parietal peritoneum
i< found projecting from the abdominal cavity beneath the ^~ k i 1 1 of the groin
(the scrotum in the male and the labium majus in the female). Later on
the testis descends along this process of peritoneum, the so-called funicular
process i processus vaginalis peritonei >, and the lower portion of the peritoneal
pouch forms the tunica vaginalis testis. Normally the upper portion becomes
obliterated, bul if such obliteration <!"<'> ii"t occur, the tunica vaginalis remains
in open communication with the interior of the belly through the inguinal
canal, and a portion of abdominal contents may descend through this canal,
constituting, as already stated, a congenital hernia, though the protrusion may
not occur until adult life. In female- the canal is known as the canal of
Xuck. Incomplete closure of the peritoneal process gives rise to hydr<
of the cord and to other conditions to be spoken of later.
The abdominal wall in the inguinal region consists of the skin and subcuta-
neous tissues, the aponeurosis of the external and internal oblique muscles, the
transversalis muscle, and the transversalis fascia. The inguinal canal contains
the vaginal process of peritoneum in early fetal life, and later the spermatic
cord or round ligament passes between these anatomical layer-. Its inner
opening, the internal abdominal ring, is an orifice in the transversalis fascia
jusl large enough to permit the passage of the cord. The outer end of the canal,
the externa] abdominal ring, is an elongated aperture in the aponeurosis of
the external oblique muscle. The internal abdominal ring lies about halfway
between the anterior superior spine of the ilium and the spine ,,f the pubis,
and abou 1 two thirds of an inch above Poupart's ligament The external ring
lies just above and to the outer side of the spine of the pubis. The deep epi-
gastric artery passes upward behind the internal border of the external ring
in front of the peritoneum and behind the transversalis fascia. The inguinal
canal is about 1.4 inches in length, and is slightly longer in females than in
males. At it- beginning its anterior or ventral wall is formed by the thick
muscular fibers of the internal oblique and transversalis muscle, and it- pofi
rior wall by the transversalis fascia. At the middle of the canal the posterior
wall is the transversalis fascia, bu1 the internal oblique and transversalis mus-
cle lie above it, and its anterior or ventral wall is formed by the aponeurosis
of the external oblique. At its superficial termination the canal passes through
the external oblique; its posterior wall is formed by the transversalis fascia,
strengthened in the last half inch by the conjoined tendon and the triangular
ligament. As the canal becomes more superficial its floor is formed for two
278 HERNIA
thirds of its extent by the shelf of tendinous fibers of the external oblique,
which broadens out to form Gimbernat's ligament.
The greater portion of the posterior or dorsal wall is formed by the trans-
versalis fascia, which is here developed into a layer of considerable strength.
Toward the median line the fibers of transversalis fascia are vertical. Later-
ally they consist of numerous fibers curving around the internal ring. Be-
tween these two parts there is a weaker portion lying to the inner side of the
deep epigastric artery, and furnishing the avenue through which direct inguinal
hernia? escape. The protection of the internal ring consists very largely of the
internal oblique muscle, and to a small extent only of the transversalis muscle ;
and it is especially the internal oblique muscle, not the so-called conjoined
tendon, which is utilized in Bassini's operation, being drawn down by sutures
to Poupart's ligament to form a new posterior wall for the inguinal canal.
(Anatomical details adapted from Joseph A. Blake, " Hernia," " Reference
Handbook of the Medical Sciences," William Wood & Co.)
Oblique Inguinal Hernia. — Oblique inguinal hernia? follows, in man, the
same path into the scrotum formerly pursued by the testis ; that is, through the
inguinal canal, and may finally reach the bottom of the scrotum; and nearly
all oblique inguinal hernise, if they reach a considerable size, pass directly along
the cord to the vicinity of the normally placed testis. The anatomical layers
covering an oblique hernia? are the same as those which cover the spermatic
cord. They are from within outward, the infundibuliform fascia, a prolonga-
tion of the transversalis fascia ; the cremasteric fascia and the cremaster muscle,
derived from the internal oblique ; and the intercolumnar fascia, derived from
the external oblique. The coverings of a direct inguinal hernia are the same,
excejjt that the transversalis fascia itself takes the place of the infundibuli-
form fascia. The various structures of the cord are spread out to a greater or
less extent over the surface of a hernial protrusion, the vas deferens lies to
the outer side and posteriorly, while the blood-vessels of the cord lie to the
outer side of the sac. In the scrotum, however, these relations may be changed,
and the entire cord may come to lie in front of the hernia. When the hernia
passes through the entire length of the inguinal canal it is known as an external
or oblique inguinal hernia. When it passes directly forward through the weak
portion of the transversalis fascia to the inner side of the deep epigastric artery
it is known as a direct inguinal hernia. The direct inguinal hernia? are always
acquired, the indirect may be either congenital or acquired. The indirect hernia
may be divided into several classes, according to the extent and anatomical limits
of the protrusion. In the earliest stages of oblique inguinal hernia it is usu-
ally possible to invaginate the skin of the scrotum or labium, as the case may
be, and to enter the inguinal canal through the external ring.
Examination of Inguinal Hernia. — For making the examination of inguinal
hernia in general the patient stands upon his feet in front of the surgeon,
who sits conveniently upon a chair with the patient facing toward his right,
if the hernia is upon the left side, or toward his left, if the hernia is upon
SPECIAL FORMS or HERNIA
L'7!>
the righl Bide, and makes the examination with his righl or left forefii
respectively. The tip of the finger invaginates the 3crotum, finds thi
terna] ring, a n< 1 is then pushed onward into the inguinal canal. In the
earliesl and slightest cases, when the patienl is requested to cough, s
tinct impulse is fell at the internal ring by the examining finger. The
mere appreciation of an impulse is hardly sufficient to make a diagnosis
of hernia, bul it' the impulse is notably greater on one side than the other,
it indicates at leasl a tendency toward the production of a bernia upon that
side or a hernia in its incipient stage. If the hernia is a little farther advanced,
a portion of abdominal contents may be felt to enter the inguinal canal at
the moment of coughing, bul returns instantly to the abdomen. With a re-
laxed abdominal wall it is sometimes possible in tliese cases to insert the finger
through the internal ring into the abdominal qavity. If the surgeon simply
inspects the abdominal wall during coughing, it is sometimes possible in these
cases to see a slight rounded protrusion, which immediately disappears. The
external ring is often notably increased in size, and there is in many of these
cases a distinct relaxation of the abdominal Avail. When operating upon a
patient of this kind, who has
a well-marked hernia upon
one side, if the conditions
such as have just been noted
are found upon the other, it
is at presenl considered wise
and justifiable to operate
upon both sides.
The third grade of ingui-
nal hernia is when the in-
guinal canal is continuously
occupied by the hernia, which,
however, forms no external
prominence on the abdominal
wall. This type is known by
various name-: incomplete
hernia, interstitial hernia,
hernia of the inguinal canal.
When slightly further ad-
vanced, a rounded swelling is
appreciable in the inguinal
region, sometimes extending
as far as the external abdom-
inal ring, but not descending
into the scrotum or labium, as the case maj be. This form is known as bubono-
cele. When the hernia descends into the scrotum, it is known as a complete
hernia, sometimes as a scrotal hernia. Sometimes scrotal hernia may reach
Fig. 38. — Oblique Inguinal Hernia (Scrotai Tytk).
(Roosevelt Hospital, collection of l>r. Charles McBurney.)
280
HEENIA
a very large size, so that a large part of the intestines descend into the scrotum,
forming a rounded pendent tumor, which may reach almost or quite to the
knees. Upon the surface of such a tumor the preputial orifice may only be
discoverable as a dimple, the penis being entirely covered and out of sight.
In such hernia? the hernial ring is usually very wide ; in some cases large
enough to admit the entire fist. These hernia? usually form adhesions, so that
they are not reducible ; and also because, as already stated, so large a pro-
portion of the abdominal contents lie habitually outside the belly that the
abdominal cavity becomes permanently contracted and too small to contain
the habitually herniated intestines. This condition is known as eventration.
These hernia? are, as a rule, inoperable. From the very large number of
arterial trunks contained in the hernia, the whole tumor may exhibit visible
and palpable pulsation.
Congenital Inguinal Hernice in the Male. — When the vaginal process of