peritoneum remains open after birth it may at any time receive a hernial pro-
trusion. The actual presence
of a hernia at birth is, how-
ever, quite rare; usually the
hernia does not occur until a
later period ; sometimes not
until adult life. It has been
found by the examination of
infants at birth and there-
after that a complete or par-
tial failure of obliteration of
the vaginal process is ex-
tremely common; and while
the results of the observations
of various observers differ
quite a little, the following
statistics are not devoid of
interest : P. Camper found in
examining 70 new-born chil-
dren that in 34 cases the proc-
ess of peritoneum remained
open on both sides, in 14
cases upon the right side, in
8 cases upon the left side.
Fere found among 188 chil-
dren up to the ninth year of life, in 59 cases either a total or partial failure of
obliteration. Kamonede examined 215 children or adults, and found among
these the process entirely open in 32 cases and only partially closed in 26.
Bull and Coley found in 500 cases of inguinal hernia operated upon in
children under fourteen years of age that less than fifty per cent of these were
Fig. 39. — Large Irreducible Scrotal Hernia.
(New York Hospital, service of Dr. Frank Hartley.)
SPECIAL FORMS <>l Ill.KXIA
28]
congenital. The congenital hernia? present at birth are very rare. In Dearly
nil of these cases :i« 1 1 n - i« >i i - are found, Bometimes a- mere cords, sometimi
broad adhesions between the contents of
the hernial sac and the test i-.
The obliteration, when it does occur,
may he partial or complete. In this
• election Sachs divided the vaginal
process of peritoneum for purposes of
descripl \<<u Into four parts : ( 1 ) The
funnel shaped process at the internal
abdominal ring. (2) The inguinal
portion lying in the inguinal canal.
i â– ; i The portion along the course of
die cord in the scrotum. ( 4 ) The por-
tion in immediate relation with the
testis.
Numerous possibilities exist in re-
gard to the obliteration of these several
parts. ( 1 ) Obliteration may occur only
in the middle of the funicular process,
that portion in the middle of the cord between the external ring and the testis;
in these eases a funnel-shaped depression may exist at the internal ring; the
tunica vaginalis testis remains <>]ien and extends upward an unusual distance.
In the second variety, the most frequent form, the peritoneal sac remains open
through the inguinal canal, below which the process is obliterated as far as
the tunica vaginalis. In the third variety the inguinal portion alone is oblit-
erated. In the fourth variety a small
funnel-shaped process merely exists at
the internal ring; the remainder is
Fig. 40. — Reducible Inguinal Hernia.
(Roosevelt Hospital, service of I Jr. Charles
McBurney. |
Fig. 41. — Hydrocele of the Tunica Vaginalis Fig. 42.— Acquired Inguinai Hernia with IIy-
i â– -ms. drocele of mo tunica vagina! -
obliterated, [rregular forms also occur in which obliteration has failed in
one or more spots along the course of the cord, and these serous cavities may
282 HERNIA
be filled with watery fluid, encysted hydrocele of the cord. Be the conditions
as they may, certain it is that a large proportion of the hernia occurring in
little boys are of the congenital variety.
The commonest and simplest form of congenital hernia in the male is when
the entire process remains open, and the hernial contents descend to the bottom
of the scrotum lying in contact with the testis. In some cases one finds at
operation a hernial sac which communicates below with the tunica vaginalis
testis by a narrow opening. In these the lower pouch may become filled with
serous fluid, which slowly or rapidly drains back into the abdominal cavity
when the patient lies down. In other cases the hernial sac will terminate
below in a fibrous cord running into the upper part of the tunica vaginalis
testis. When operating upon cases of congenital inguinal hernia one finds
usually a very thin sac closely adherent to the elements of the cord and sepa-
rated only with considerable difficulty; the vas deferens lies posteriorly, as a
rule, and the veins are spread out upon the external and posterior surface of
the sac. It is not, however, always possible to distinguish, even at the time
of operation, between an acquired hernia and that type in which the process
remains congenitally open merely a certain distance down the cord, but short
of the tunica vaginalis. Before operation it is seldom if ever possible by the
physical signs to distinguish the congenital from the acquired form of inguinal
hernia.
Another form of inguinal hernia exists, sometimes known as infantile her-
nia. It is always an acquired hernia. In infantile hernia the processus vagi-
nalis may be entirely open or partly obliterated, but the hernia occurs in an
acquired sac. Thus in these cases it might happen that the hernia would
appear to be surrounded by a double sac.
Certain congenital defects relating to the testis and to the tunica vaginalis
— namely, undescended testis or misplaced testis and hydrocele — have a rather
important practical relation to hernia. The descent of the testis may be abnor-
mal or incomplete. The testis may fail to leave the abdomen, and may remain
in the iliac or lumbar region. It may descend a variable distance into the
inguinal canal ; it may leave the canal and lie upon the pubes or beneath the
skin of the thigh or in the perineum. These congenital defects in the descent
of the testis are frequently associated with an unusually wide inguinal canal,
the processus vaginalis descends below the testis, and may remain open in these
cases a variable distance and give rise to a congenital hernia. In the cases
where the testis remains in the inguinal canal, it may often be pushed out of
the external ring, but usually returns at once to its former situation, and this
condition is not infrequently accompanied by a congenital hernia, in which the
hernial sac lies in front of the testis. Certain practical interest attaches also
to the cases where the processus vaginalis remains open throughout, but is
extremely narrow at some point, so that serous fluid accumulates in greater or
less quantity below the narrow point. If the opening is large, fluid will only
accumulate when the individual stands erect, and will run back into the abdom-
SPECIAL FORMS OF HERNIA
inal cavity more or less completely when he lies down. If the communication
is very narrow, the fluid will run back but Blowly, and ii is possible in these
cases i" confound the condition with an irreducible hernia, or with a hernia
which is reduced only with difficulty. The differentia] diagnosis is to be made
by the lighl tesl and by the fad thai when a hernia leaves the abdominal cavity
and descends into the sac, it usually does so suddenly and at once, upon cough-
ing, straining, or the like; whereas, in the case of these communicating hydro
celes, the accumulation, having once been emptied into the belly, returns but
slowly. Still another combination may exist. The upper portion of the vaginal
process may be the seat of a hernia which communicates by a oarrow orifice
with the tunica vaginalis below, and scroll- fluid may accumulate in this lower
portion of the sac.
Fig. 43. — Acquired Inguinal Hernia with an Ac- Fig. 44. — Congenital Hernia with HYDRO-
CUMULATION OF FLUID IN THE HERNIAL SAC. CELE OF THE HERNIAL Sac.
The various forms of hydrocele are occasionally confounded with hernia.
The simplesl form, hydrocele — i.e., of the tunica vaginalis testis — occurs very
commonly among children, hut also during later life. It form- a rounded or
ovoid tumor, elastic, tense, and Huetuatiiiii, transmits light readily, unless the
sac be very thick, is insensitive and irreducible, and shows no impulse on cough-
ing. Jn some cases, if the vaginal process remains open a considerable dis-
tance along the cord, the tumor will end above in a more or less spindle-shaped
prolongation. The presence of the testis may he determined, usually by palpa-
tion, as a firm ovoid mass, and also quite definitely by the sensations of the
patient. If the testis he squeezed between the Angers tin- peculiar and rather
indescribable testicular sensation is produced, easily recognizable by the patient.
The sensation, if firm pressure is made, amounts to actual pain, and may pro-
duce slighl faintness. A hydrocele is flat upon percussion. In using the lighl
test one should he cautious in assuming that no hernia is present in little
children, because, as already noted, lighl is freely transmitted through the gut
284 HERNIA
in infants. When the hydrocele extends far up the cord into the inguinal canal,
for example, the difficulties of diagnosis may he rather greater, and this will
be especially the case if two sacs exist, one above and one below, communicating
by a narrow orifice or not communicating at all. This condition is known as
bilocular hydrocele. Occasionally the upper portion of such a sac may com-
municate with the abdominal cavity, and may thus be reducible. It is not
to be forgotten that various forms of hydrocele may be associated with hernia,
and that the sac of the hydrocele may bear various and often rather compli-
cated relations to the hernial sac itself. Some of these conditions are rather
puzzling to the surgeon, and many of them only permit of a diagnosis by an
open operation. The appended series of diagrams illustrate the several possi-
bilities. One of the classical forms of the condition was first described by Sir
Astley Cooper, and was designated by him encysted hernia. He assumed that
there existed a congenital inguinal hernia, and that the processus vaginalis
was closed merely at the external inguinal ring, remaining open above and
below. As such a congenital hernia makes its way farther downward into the
scrotum, it presses upon the extensive hydrocele of the cord existing below,
and may finally cause a depression in the hydrocele sac, such that in the end
the walls of the hydrocele come to be an outside double serous covering for the
lower portion of the hernia.
Interstitial Hernia. — This is an unusual form of inguinal hernia, in which
the sac occupies a position between the layers of the abdominal wall. It is
said to occur about once in 1,100 cases. Relatively, it is somewhat more com-
mon in females than in males. Three varieties are recognized: (1) The sac
insinuates itself between the transversalis fascia and the parietal peritoneum.
(2) The sac lies between the internal oblique muscle and the aponeurosis of
the external oblique. This is the most frequent form. (3) The sac lies between
the aponeurosis of the external oblique and the skin.
The first variety was termed by Kronlein properitoneal hernia. Varieties
2 and 3 produce an external, visible, and palpable tumor. In the properi-
toneal variety no visible protrusion is present, and this form is very commonly
associated with a scrotal or labial hernia. Indeed, the sac of a properitoneal
hernia is quite commonly a secondary pouch communicating with the sac of
an ordinary hernia. The danger of producing this form in the attempt to
reduce a strangulated hernia has already been noted, and in several instances
such an apparent reduction has been the cause of the patient's death. In a
large proportion of the cases of properitoneal hernia, according to Macready in
sixty-seven per cent of the cases in males, there was incomplete descent of the
testis. Incomplete closure of the canal of Nuck usually coexists in females.
Varieties 2 and 3 may attain a very considerable size. They are seldom suc-
cessfully treated by mechanical means, and usually require an operation.
Direct Inguinal Hernia. — In this form of hernia the condition is never
congenital, but always acquired. It is very rare in children, and seldom is
developed until adult life. It is more common in men than in women. As
SPECIAL FOKMS OF HERNIA
compared with the indirect or oblique form "1 inguinal hernia, it- frequency
is said i" be seventeen oblique to one direct A- already ooted, the protrusion
occurs nol through the inguinal canal, but directly forward to the inner side
of the deep epigastric artery, and so through tin- external abdominal ring.
The differences in the coverings of the sac have already been noted. Direct
inguinal hernia is rare before the fortieth year of life, and usually occur- in
individuals with a flabby and feebly developed abdominal wall. It is :
a sudden, but always a gradual protrusion. It quite frequently occur- upon
both sides. The shape of the hernia is often spherical. It seldom attain- a
large size, and tends to spread toward the median line rather than downward
into the scrotum. Indeed, if we sec a hernia of considerable size protruding
through the ( sternal abdominal ring, hut not descending into the scrotum, the
probabilities are that it is a direct hernia. The diagnosis can sometimes be
made by inserting the forefinger into the external ring and feeling the pulsa-
tion of the deep epigastric artery to the outer side. The sac of direct inguinal
henna hears no such intimate relations to the structures of the spermatic cord,
as is the ease with oblique inguinal hernia. The cord lies to the outer side
or behind the hernia, and quite separate and distinct from it. Although these
hernia? seldom attain a size larger than a goose ogg, large and quite commonly
double, direct inguinal hernias have been observed. They are very much less
likely to become strangulated than the ob-
lique variety.
Fia. 45.— Entystf.d Hydrocele oethe Conn FlQ. 46. — Acqt'ired Inguinal Hernia Lttng in Frok i
wiim Acquired [ngi inal Hernia. of an Encysted Hydrocele ok the Cord.
Inguinal Hernia hi /lie Female. — The occurrence of inguinal hernia in
female children is relatively rare. It i< not usually possible t" distinguish
even at the time of operation whether these hernia 1 are congenital or acquired.
In later life, after the twenty-fifth year, inguinal hernia in the female is more
common. Repeated pregnancies appear i<> be a predisposing cause. As the
hernia increases in size it passes through the same grades as in the male,
except that it finally descends into the labium majus, in only about four per
286
HERNIA
cent of the cases, however. These hernia? rarely attain a large size, and even
when they descend into the labium very large sacs are seldom observed. In-
stead of descending into the labium they may, in case the tissues are very lax,
descend beneath the subcutaneous tissue of the thigh. Strangulation and irre-
ducibility is relatively rare in inguinal hernia in the female. Operation pro-
duces almost uniformly satisfactory results in nonstrangulated cases. Hydro-
cele also occurs in the female from imperfect obliteration of the canal of
INTuck ; and, as in man, hernia and hydrocele may exist in the same case. The
differential diagnosis of hydrocele of the canal of Nuck from hernia is usually
not difficult. The hydrocele tumor is globular or ovoid in shape, is freely
movable, is situated in the inguinal canal, or may be readily pushed into the
Fig. 47. — Acquired Hernia, the Sac Sur-
rounded in its Lower Part by an En-
cysted Hydrocele of the Cord.
Fig. 48. — Acquired Hernia in the Lower Por-
tion of the Sac Surrounded by a Fluid Ac-
cumulation in the Tunica Vaginalis Testis.
canal ; it is rarely, if ever, reducible into the abdominal cavity ; it gives the
sense of elastic fluctuation on palpation. There is a history of a slow and
painless growth without any of the symptoms which commonly accompany
hernia.
Femoral Hernia. — In femoral hernia the sac descends within or alongside
of the femoral sheath inclosing the femoral vessels. The most common situation
is through the femoral canal to the inner side of the femoral vein, rarely in
front of or to the outer side of the femoral vessels.
Anatomical Remarks. — The femoral sheath is formed by a funnel-shaped
process of the transversalis fascia, which descends below Poupart's ligament
in the thigh to inclose the femoral vessels. It is normally funnel-shaped, and
at its upper part or base the funnel is not entirely filled by the vessels. At
the apex of the funnel opposite the saphenous opening the sheath is closely
adherent to the vessels. A space thus exists at the base of the funnel to the
inner side of the femoral vein known as the crural canal. It is bounded in
front by Poupart's ligament, on the inner side by Gimbernat's ligament, poste-
SPECIAL FORMS OF HERNIA
287
i-j,, r | v |,\ the ileo-pectineal line, the Bo-called Cooper's ligament, and by the
fascia covering the pectineus muscle. To the outer side liea the femora] ein.
I i,; i<). — Hydrocele op the Tunica Vaginalis Fig. 50.— Tuberci losis oi Testis Compi icati d
Testes Complicated hy Oblique [nguinal by Inguinal Hkrnia. (Roosevelt Hospital
Hernia. (Roosevelt Hospital, collection of collection of Dr. Charles McBurney.)
Dr. Charles McHurney.)
This space is filled with loose, fatty connective tissue and contains a small
lymph node. Formerly the relation of the obturator or deep epigastric artery
t.> the superior orifice of the
crura] canal was considered
very important from a surgi-
cal point of view. The deep
epigastric artery ascends to
the abdominal wall at the
outer side of the canal. Tn
alioiit one third of the eases
the obturator artery is a
branch of t he deep epigasl ric.
Tn all hut three per cent, of
these cases the ohturator pusses
d< iwnward to the outer side id
the femoral opening; in the
remainder it arches over this
opening and passes to its in-
ner side, and thus when op-
erating upon a strangulated
femora! hernia the surgeon
miffhl wound the obturator ar- Fig. 51.— Femorai Hernia. The patient was an old woman;
the hernia was recurrent. No operation was done, (New
terv when dividing the fibers York Hospital collection.)
288
HERNIA
of Gimbernat's ligament from within, cutting toward the median line to
relieve the constriction. At the present period of liberal incisions and of
operating under the control of the eye such an accident is not very likely
to occur; and, if it is does, the control of the hemorrhage by ligature offers
no especial difficulties.
The coverings of a femoral hernia, if it descends through the crural ring to
the inner side of the femoral vein, are the peritoneum, the subperitoneal fat,
often quite abundant, the so-called septum crurale, the transversalis fascia, the
cribriform fascia, the superficial fascia, and the skin. The hernia appears in
the thigh below Poupart's ligament and below and to the outer side of the spine
of the pubes. The relations of the hernial protrusion to Poupart's ligament and
to the spine of the pubes are the anatomical landmarks whereby we distinguish,
femoral from inguinal hernia. The inguinal hernia? escape through the exter-
nal ring above Poupart's ligament, above and to the inner side of the spine
of the pubes. It is usually possible by careful palpation, except in very fat
subjects, to recognize the spine of the pubes and its relations to the hernial
orifice. When a femoral hernia appears in the thigh it is a small, globular, or
hemispherical mass. If it increases in size it tends to ride upward over the
falciform process of fascia lata on to the anterior abdominal wall rather
than to descend on the thigh,
although such a descent is
possible, and cases have been
observed where a femoral
hernia has descended beneath
the subcutaneous tissues al-
most as far as the knee.
Most of these hernia?, how-
ever, remain of small size,
and rarely extend upward
farther than Poupart's liga-
ment. Femoral hernia? are
more common in women than
in men, in the proportion of
about three to one up to the
age of fifty years, after which
the proportions become near-
ly equal on account of the
infrequent formation of her-
nia? in old women.
The statistics of the Hospital for Ruptured and Crippled in the city of ISTew
York indicate that inguinal hernia is about seventeen times as frequent as fem-
oral hernia. According to Macready, of 100 ruptures in males 9H per cent
are inguinal and 2^ per cent femoral hernia. Among women the proportion
is 60.3 per cent inguinal, 39.7 per cent femoral hernia. A number of rare
Fig. 52. — Femoral Hernia Incarcerated.
(New York Hospital, service of Dr. Hartley.)
SPECIA1 I OEMS OF HERNIA
varieties of femora] hernia have been described: ( 1 i The hernia; may take
place through a renl in Gimbernat'a ligament. (2) Instead "I" becoming sub-
cutaneous, the hernia? ma} burrow beneath the pectineal fascia among the
The hernia may occur to the outer
Fiq. •">:?. — Recurrent Femoral Hernia.
(New York Hospital, service <>i I >r. P. 11. Bolton.)
adductor muscles of the thigh,
of i li«' femora] artery, i I )
The hernia may escape from
the pelvis behind the femoral
\ esse] s. ( 5 ) Two sacs may
develop <>r ;i dividing sac, one
of which follows the crural
canal, the other burrows be-
tween tin- peritoneum and the
fascia "I" the pelvis, usually
downward in the direcl ion of
the obturator foramen.
The symptoms produced
by femora] hernia? are indefi-
nite pains, digestive disturb-
ances, and sometimes acute
attacks of colicky pain, re-
ferred to the lower part of
the abdomen, [nasmuch as
these hernia' grow very slow-
ly and do not form large
tumors, their existence may remain unsuspected for a very considerable
time. When small they are usually easily reducible, but otherwise give
the ordinary signs of hernia, when examined carefully in the erect position.
Strangulation occurs in femoral hernia, on account of the very narrow
orifice, much more frequently than in inguinal hernia'. Thus, among 9 1-
cases of strangulated hernise Bryant found 50 inguinal and 14 femoral hernia'.
The seat of strangulation in femoral hernia may be at the crural rinir, the
border of Gimbernat's ligament, the falciform process of fascia lata, or in
the substance of the cribriform fascia. The two most frequent points are the
border of Gimbernat's ligament and the edge of the falciform process. Stran-
gulation of femoral hernia leads very rapidly to gangrene of the bowel, and
strangulation of a partial hernia, involving but a portion of the wall of the gut,
is not infrequent. The symptoms of strangulation may be far less stormy than
Is the case with inguinal hernia', and yel at the operation the bowel may be
found gangrenous. The use of taxis for the reduction of <i strangulated f< moral
h< diki is not advisable, nor can femoral hernia of the reducible kind be cured
by mechanical means other than operation.
Differential Diagnosis of Oblique Inguinal Hernia. — "While many of the
details of the diagnosis of inguinal hernia have already been mentioned, cer-
tain of them may hear repetition, and some other conditions nol yel described
290 HEENIA
require notice. The differential diagnosis of femoral from inguinal hernia
depends chiefly upon the relations between the hernia and the two anatomical
landmarks : the spine of the pubes and Poupart's ligament. In the male the
diagnosis is usually not difficult. The external ring may always he felt, and
the pubic spine may be located by introducing the tip of the finger into the
canal and following the external pillar of the ring to its insertion into the
spine of the pubes. In females, if they be stout, the diagnosis is sometimes
very difficult or impossible. If the protrusion is above Poupart's ligament,
it is an inguinal hernia ; if below, a femoral hernia. If Poupart's ligament
cannot be felt, a line may be drawn from the anterior spine of the ilium to
the spine of the pubes. If the hernia appears to lie above this line it is prob-
ably inguinal ; if below, femoral.
Hydrocele.- — Here it may be said that encysted hydrocele of the cord or
of the canal of Xuck can usually be distinguished from hernia readily; the
positive signs of hernia — impulse on coughing, reducibility, etc. — are wanting;
the tumor is rounded, elastic, movable, and more tense than a hernia, except the
latter be strangulated.
Lipomata. — Fatty tumors of the groin will exhibit the physical characters
of lipoma — i. e., softness, a lobulated structure, a want of complete corre-
spondence with the anatomical site of hernia, absence of a pedicle or neck,
irreducibility. They are usually subcutaneous and attached to the skin. (See