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the contents of the sac from the surface of the body.

When the funicular process becomes closed at its lower extremity only,
the hernia descends into this process, as in the congenital form, but does

3 L 2




Fig. 342. — An oblique inguinal hernia.
(From the Museum of St. George's Hospital.)



884 IXJURIKS AND DISEASES OF SPECIAE DROANS







Flc. 343. — \'arieties of inguinal hernia.
a, sac of hernia ; fi, tunica vaginalis.
I. Common scrotal hernia ; 11. Con-
geniial hernia ; III. Infantile hernia ;
IV. Encysted hernia ; v. Hernia
into the funicular process. {From
Gray's ' Anatomy.')



IX ii;i<si rriAi, iii:knia



885



not conic in contact willi the testicle, for it is separated from it by the
occlusion which has taken place. This is known as herfiia of the funi-
cular process (fig. 343, v). In the female, in like manner, the process of
peritoneum which accompanies the round ligament may remain patent,
though it is usually ol)literated at birth. If it should remain [)atent, under
rare circumstances a hernia may descend into it, and constitute a form of
hernia analogous to the congenital hernia in the male. When, however,
an inguinal hernia occurs in the female — and it is the common form of
hernia found in female children— it is usually of the acquired variety.

Interstitial hernia.— In connection with the subject of the defec-
tive development of the coverings of the testicle, must be mentioned a
form of hernia which is known as interstitial hernia, and which is usually
a variety of the congenital form (fig. 344). In these cases there is a
diverticulum or pouch, springing from the patent funicular process, or
patent canal of Nuck, which forms a sac into which the gut may find its
way. The sac is situated between the layers of the abdominal parietes,
and may be placed either between the external
oblique muscle and the subcutaneous structures ;
or between the internal and external oblique ; or
between the transversalis fascia and the peritoneum.
Two explanations have been given of the mode in
which this diverticulum is produced. Some believe
that it is a congenital malformation, and that an
additional sac is formed as the result of some
aberration in the developmental process ; but there
is no evidence that this is so. It seems more
probable that it is due to some tightness of the
external abdominal ring, which prevents the bowel
descending through it, and therefore the bowel forces
its way, pushing the sac before it, in the direction
in which there is least resistance. This is rendered
the more probable by the fact that interstitial hernia
is usually associated with undescended testicle.

Symptoms. — Nothing much need be said about
the signs of a complete inguinal hernia, as they have
been already described (page 864). It forms "a
tumour in the scrotum, which lies generally above and

in front of the testicle, and is pyriform in shape. Its neck can be traced
upwards into the inguinal canal, the cord generally lying behind it, with its
constituents obscured by the presence of the hernia. In many cases of
oblique hernia there is a fullness along the course of the inguinal canal,
but when the hernia is of long standing the mouth of the sac becomes
enlarged, and the internal ring becomes displaced downwards and inwards,
so that it is situated directly behind the external ring ; the hernia will then
be felt to project directly backwards from the external ring, there will be
no oblique fullness in the situation of the inguinal canal, and it is impos-
sible to diagnose it, by examination, from a direct inguinal hernia. The
diagnosis of femoral hernia from a complete inguinal hernia is usually
easy ; but in some cases of large femoral hernice, which have a tendency to
roll up over Poupart's ligament, a mistake may be made. The diagnosis
can, however, be settled by placing the finger on the spine of the os
pubis : the neck of the femoral hernia is external to this point ; that of
an inguinal hernia internal. It should be noted also whether the neck of




Fig. 344. — Interstitial
hernia. Diagram-
matic.



<S86 INJL'kIi:s AND DISEASES OI' Sl'ECIAE ORC.AXS

the sac is above I'ouparl's ligament, when it will he an inguinal hernia, or
below it, as in the femoral variety, 'i'he diagnosis of a complete inguinal
hernia from other scrotal swellings ought not to be difficult. 'J'he swellings
with which it is liable to be confounded are hydrocele, h;ematocele, solid
tumours of the testicle, inflamed testicle, and varicocele. In all these,
except varicocele, the diagnosis may at once be made by grasping the
structures wiiich pass through the external abdominal ring with the finger
and thumb. If the case is one of a scrotal swelling other than a hernia
or a varicocele, the structures of the cord will be felt distinctly passing into
the canal, and the swelling will be completely i.solated from the ring. In
case of a hernia, on the other hand, the limit cannot be defined, and the
structures of the cord will be masked by the neck of the hernia. The
only cases in which possibly there might be a fallacy in this test are where
the funicular process is patent throughout the greater part of its length, but
closed at the internal abdominal ring. If a collection of fluid were to take
place under these circumstances into the tunica vaginalis, it would distend
the funicular process, and the spermatic cord would be obscured upon
grasping the scrotum just below the external ring. But in these cases
translucency and other physical signs of hydrocele would be present. The
diagnosis between varicocele and hernia need not be dwelt upon. The
peculiar swelling which is produced by varicose spermatic veins is so
characteristic that no mistake is likely to be made except by the most
careless observer. In the female, a labial hernia may be mistaken for a cyst
of the labia ; but tlie latter is irreducible, well defined, and limited above.

In incomplete hernia, or bubonocele, there is a small rounded
or oval swelling in the course of the inguinal canal, in which there is an
impulse on coughing. It is generally movable, and is reducible under
ordinary circumstances. Its diagnosis is sometimes difficult, and it is liable
to be mistaken for encysted hydrocele of the cord, enlarged gland, re-
tained testicle, ha^matocele of the cord, fatty tumour, and chronic abscess.
Those swellings which are situated in the cord, such as encysted hydrocele
and hematocele, may be at once differentiated, by the fact that they are
irreducible if the testicle is fixed by the hand so as to make traction on
the cord, though they may be movable and capable of being j)artially
pushed upwards into the abdomen if no traction is made. From a retained
testicle it may be diagnosed by the absence of the testicle from the scro-
tum, and by the clear defined upper border of the swelling. It must be
borne in mind, however, that a hernia is very frequently associated with
an undescended testicle. From enlarged glands the diagnosis can be made
by introducing the finger into the canal through the external ring, by
invaginating the scrotum ; the swelling will then be found to be superficial
to, instead of being in, the inguinal canal. The .same plan maybe adopted
in diagnosing a chronic abscess in the abdominal wall from a bubonocele.
The consistence of the swelling also, which is soft and fluctuating, di.s-
tinguishes it from the definite tense outline of a hernia. Fatty tumours
are occasionally met with in the inguinal canal, and can be recognised by
their defined upper margin, which may sometimes be made out to be
lobulated, and by the absence of any impulse on coughing.

The existence of a congenital hernia may generally be surmised by the
history of its sudden descent, in contradistinction to the gradual descent
of an acquired hernia. For it must be remembered that a congenital
hernia is not necessarily a hernia which is apparent at birth, but one
which takes place through a congenital opening.



FEMORAL MKRNIA 887

Direct inguinal hernia is far less common than the oblicjiic.
In these cases the hernia [)rotrudes directly through the external abdo-
minal ring ; the sac being formed by that portion of the peritoneum which
lines Hesselbach's triangle, a s[)ace bounded externally by the epigastric
artery, internally by the outer border of the rectus muscle, and below by
Poupart's ligament. 1 )irect hernia, in the male at all events, is always
of the acquired type. Two varieties of this hernia are described : one
where the hernia leaves the abdomen to the inner side of the obliterated
hypogastric artery ; the other, where it emerges to the outer side of this
structure. This makes a slight difference in the coverings of these two
forms. In the one to the outer side of the obliterated artery there are the
same coverings as the ordinary oblique hernia ; whereas the one to the inner
side, which is the more common of the two, has the conjoined tendon as
a covering, instead of the cremasteric muscle and fascia. This is a matter
of very little importance; the essential point to bear in mind is that one
form of direct hernia is in close relation with the epigastric artery, and
therefore, in dividing the stricture in a strangulated inguinal hernia, the
incision should always be made directly upwards, that is to say, parallel
to the artery. Under these circumstances the epigastric vessels, whether
the hernia is oblique or direct, cannot be wounded.

Femoral hernia. — Femoral hernia occurs more commonly in the
female than in the male, although it is by no means rare in men. It most
usually occurs between the ages of twenty and forty, and is uncommon in
female children. It is never of the congenital form, but is always acquired.
The hernia passes out through the crural ring and descends vertically through
the crural canal, and then bends forwards through the saphenous opening
to appear under the skin. It is in close relation on its outer side with the
femoral vein, from which it is separated by a thin septum ; the spermatic
cord or the round ligament passes above and internal to the femoral ring,
but is superficial to it ; while the epigastric vessels skirt its upper and
outer margin. The pubic branch of the obturator artery passes round the
ring in its passage to anastomose with the pubic branch of the epigastric,
and varies considerably in size. In one case out of three and a half the
obturator artery arises from the deep epigastric, and in some of these cases
curves inwards along the free margin of Gimbernat's ligament to reach the
obturator foramen ; under these circumstances it is in danger of being
wounded in di\iding the stricture. In the majority of cases, however, in w^hich
the obturator artery has this anomalous origin, it skirts round the external
ihac vein, on the outer side of the ring, and is then in no danger of being
wounded. A femoral hernia, after emerging from the saphenous opening,
has the following coverings : skin arid subcutaneous tissue, cribriform fascia,
anterior layer of the femoral sheath, septum crurale, sub-serous areolar
tissue, and peritoneum. A femoral hernia is usually small, and, after it has
emerged through the saphenous opening, has a tendency to pass obliquely
upwards and outwards along the line of Poupart's ligament ; and it is under
these circumstances that it is liable to be mistaken for an inguinal hernia.
Femoral hernia most frequently consists of intestine, and generally ileum ;
it is very liable to become strangulated, but is not often irreducible.
Omental hernia is not nearly so common in the femoral region as in the
inguinal ; when it does occur, the omentum is very liable to contract
adhesions, and the hernia to become irreducible.

Symptoms. — The signs of a femoral hernia are the ordinary signs of
hernia— a reducible swelling, with an impulse on coughing, in the groin to



8SS I\JLKIi:s AM) J)1.S1:A.SES ok Sl'lXIAL {)k(;A\S

the inner side of the femoral vessels, and outside the pubic spine. It may
be mistaken for some other affections. An enlarged gland situated in the
crural canal may closely simulate a small hernial tumour, and indeed, in
fat persons, a diagnosis can sometimes hardly be made without an explora-
tory incision. In some not uncommon cases a small hernia may be found
underneath an enlarged gland, which makes the diagnosis still more
uncertain. As a rule, a gland is defined and separable from neigh-
bouring parts ; it is movable, and has no impulse on coughing. A
femoral hernia may be mistaken for a psoas abscess : in both there
is a reducible tumour, with an impulse on coughing ; but in the psoas
abscess the swelling is outside the femoral artery, and there is distinct
fullness in the iliac fossa, and fluctuation can usually be obtained by
alternating pressure above and below Pou])art's ligament. Varix of the
saphena vein is said to simulate femoral hernia ; but if the swelling is
reduced and pressure is made over the femoral ring, and the patient stands
up, the swelling of varix will reappear ; that of hernia will not.

Treatment. — Femoral herniae, as a rule, cause far less inconvenience
and pain than inguinal hernije, and many of these cases may very well be
treated by making the patient wear a truss. A radical cure is not so often
called for as in the inguinal variety. If they become strangulated, the
treatment must be conducted on the principles enunciated above (page 877).
In dividing the stricture the incision should be made upwards and inwards,
and, after the gut has been reduced, one of the methods enumerated for
effecting a radical cure should be adopted (page 871).

Umbilical hernia. — There are three different varieties of umbilical
hernia: i. congenital : 2. infantile : 3. umbilical hernia of adults.

1. Congenital, or exomphalos. — The congenital umbilical
hernia is due to an arrest in the process of development, from imperfect
closure of the ventral plates. It may vary very much in degree : the
abdominal wall may be unclosed from the ensiform cartilage to the
symphysis pubis, and the whole, or almost the whole, of the abdominal
viscera may be extruded. This condition is incompatible with life, and is
only rarely met with. More commonly the ventral plates have met together
above and below, and the deficiency is only at the neighbourhood of the
umbilicus. The intestine, generally the caecum and adjoining portion of
the ileum, then protrudes and becomes enclosed in the tissues of the cord,
which is generally to be seen issuing from the summit of the swelling.
The coverings are very thin, and the coils of intestine can usually be seen
through them. If left untreated, the cord separates, the abdominal cavity
is opened, and the child dies of peritonitis. In addition to these cases,
which are the most common, there may be a minute opening in the
al)dominal wall, through which a very small portion of intestine, or in
some cases a Meckel's diverticulum, may be protruded, and may be over-
looked at the time of birth. Cases have been recorded where, in such a
case, the gut has been included in ligaturing the cord. The only treatment
is to at once open the sac, reduce the intestine, and close the gap by
sutures.

2. Infantile. — This is the umbilical hernia of infants, and is an
exceedingly common affection. It is not a congenital condition, but
appears some weeks after birth, and is caused by the yielding of the
umbilicus. It is predisposed to by phimosis or constipation, the strain-
ing in attempting to pass water or defecate causing the soft cicatricial
tissues to give way. It is common to both sexes, but is much more amen-



LMiUI.K AL HKRMA




hernia,
of St.



able to trcatnicnl in the male than in the female. It presents a soft button-
shaped swelling at the umbilicus, which becomes tense \vhen the child
cries or strains. It appears to cause absolutely
no inconvenience, and has a tendency to
undergo spontaneous cure as the child grows.
The treatment consists in simply applying a
transverse piece of strapping so as to approxi-
mate the edges and prevent the protrusion.
If the child is the subject of phimosis he
should be circumcised, and his bowels should
be regulated.

3. The umbilical hernia of adults
(fig. 345). — This name is somewhat of a
misnomer, as the hernia is not situated at the
umbilicus, but either just above or below it,
more frequently in the former situation. It is
much more common in women than in men,
and occurs in women who have borne children
and have large pendulous abdomens. It
usually occurs in women over thirty, increases
gradually, and may eventually attain a very
large size. It most frequently contains the
transverse colon and omentum, and to this may
be superadded coils of small intestine. These
structures become matted together by adhe-
sions, and are very often adherent to the sac,
so that the hernia is very frequently irreduci-
ble. The coverings are thin. The peritoneum
is often so thinned and attenuated that it is scarcely recognisable. The skin
and subcutaneous tissues over the tumour are also thinned and stretched,
so that the coils of intestine may be seen through the covering. The
integumental structures are liable to ulcerate and give way. A consider-
able deposit of fat often takes place i'n the herniated omentum, and this
gives to the tumour a lobulated appearance, and is a further cause of its
irreducibility. It is very liable to become obstructed, and this obstruction
may, and often does, run on to strangulation.

Symptoms. — There is no difficulty in recognising the condition. A
tumour is to be seen in the neighbourhood of the umbilicus, which is
usually irregular and lobulated. If of large size, it is pendulous and has a
rounded and wide base. There is a distinct impulse on coughing, and it
may or may not be reducible : usually the latter. The patient is frequently
troubled with dyspeptic symptoms, colicky pains, constipation alternating
with diarrhiea, and often nausea and vomiting.

Treatment. — In tho.se cases where the hernia is reducible, an umbilical
truss should be worn. This consists of a modified Salmon and Ody's trus.s,
consisting of a plate over the site of the protrusion, and another over the
back ; the two being connected by a spring, which is attached to the
front plate by a universal joint. In very fat patients there is great difficulty
in keeping this in its place. If the hernia is irreducible, a concave pad
fixed in an abdominal belt should be worn ; or if the hernia is very large,
a bag truss must be adapted. As an irreducible umbilical hernia is a con-
stant source of discomfort and danger to the patient, an operation for the
radical cure should always be seriously considered. Those cases w-here



Fic;. 345. — Umbilical
(From the Museum
George's Hospital.)



890 IXJLRIKS AND DISEASES OF Sl'ECLVL ()R(iANS



the hernia is not of very great size, and the patient is not very fat, are the
ones suited to operation. If the hernia is large and the patient fat, there is
no room in the abdomen for the prolapsed structures ; and if the operation is
attempted it will probably end in failure, from inaVjility on the part of the
surgeon to reduce the contents of the sac. If, however, the hernia is not
very large, though the patient is corpulent, it is justifiable to attempt, by
dietetic and other measures, to reduce the corpulency, and if this can be
done, to then proceed to the operation. The manner of performing it has
already been described (page 872).

Strangulation of an umbilical hernia is always a verj- serious condition ;
but many of the cases of so-called strangulation are really more of the
nature of obstruction — a condition which is almost as serious as strangu-
lation, and may lead to the death of the patient, unless relieved by
operation. Herniotomy itself m these cases is attended with a very heavy
mortality, though it has been considerably reduced in recent years, since
the establishment of antiseptic measures, and since it has become the prac-
tice to shut off the peritoneal cavity from the external wound. The opera-
tion consists in opening the sac by a vertical incision in the middle line,
dividing the stricture, and reducing the intestine, after the adhesions, if
any exist, have been separated. The omentum is now freed from the
interior of the sac, tied in strands, and removed. The sac is then excised,
the cut edges of the peritoneum sutured together with a continuous
catgut suture, the opening in the abdominal wall securely closed by
buried sutures, and the edges of the external wound adjusted. Howard
Marsh, in order to save time in the performance of the operation,
recommends that the sac and omentum should be removed together,
without any attempt being made to separate them. He makes a semi-
circular incision on either side of the sac, so as to include in an elliptical
wound the skin over the front of the tumour, leaving only so much on either
side as will allow of the closure of the wound in the middle line, without
tension. He then separates the subcutaneous tissues from the outer

surface of the sac on either
side, down to its neck. The
sac is now opened ; the stric-
ture, if one exists, is divided,
and the intestine is reduced.
The surgeon then defines and
isolates the omentum at the
spot where it passes through
the abdominal wall, ligatures
it in segments, and divides it
just beyond the ligature. By
now cutting through the neck
of the sac external to the
ring, the omentum, the sac,
and the skin covering the
front of it are removed in one
mass. The cut edges of the
sac are now united, the ring
obliterated by buried sutures,
and the external wound closed.
Obturator hernia (fig. 346) is where the hernia descends through
the upper part of the obturator foramen. It is most common in women




Flc. 346. — Obturator hernia. There is also a small
inguinal hernia just appearing at the external
abdominal ring. (From the Museum of St.
Cieorge's Hospital.)



VENTRAL HERNIA



S91



who are advanced in life, and usually consists of intestine, omentum being
rarely found in these cases. It is not often diagnosed, except it becomes
strangulated, and then, in addition to the ordinary signs of intestinal
obstruction, there is to be found a tumour, or at all events a perceptible
fullness just below the spine of the os pubis, to the inner side of the femoral
vessels. In very nearly half the recorded cases, pain was complained
of about the inner side of the knee, owing to pressure on the obturator
nerve. This symptom and pain over the site of the rupture, increased by
moving the thigh and especially by tensing the obturator externus, may
give some clue to the nature of the case. An examination by the vagina
or rectum may assist the surgeon in arriving at a diagnosis.

The treatment is usually confined to those cases where strangulation
has occurred. An incision should be made along the border of the adductor
longus, and this muscle exposed and separated from the pectineus, when
the tumour will come into view. After the sac has been opened, the stric-
ture should be divided in an upward direction, as the obturator vessels are,
as a rule, at the outer and posterior part of the sac.

Ventral hernia. — By the term ventral hernia is meant a protrusion
through some part of the abdominal wall, other than those weak spots,
which are the common site of hernia, the internal abdominal ring,
the femoral ring, and the umbilicus. They may be of two or three
different varieties, (a) The most common form of ventral hernia is the
traumatic ventral hernia, where a wound or opening has been made in
the abdominal wall, or where an abscess has formed in this situation, and
the cicatricial tissue which closes the gap has yielded under the pressure
of the contained viscera. This form may also occur after rupture of the
abdominal muscles (fig. 347). The hernia presents an ill-defined bulging,




Vie.



347. — \'entral hernia following rupture of the rectus muscle.
(PVom the Museum of St. George's Hospital.)



apparent when the patient is in the erect position, and is often attended by a
feeling of weakness in the part, and by colicky and dyspeptic symptoms.
(d) Occasionally a ventral hernia may be produced by a separation of the
two recti in the middle line, and a thinning of the linea alba, generally in
w'omen who have borne children. The hernia then takes the form of an
elongated swelling, which appears in the median line of the abdomen
upon making any muscular effort. It is not usually attended by any serious



892 INJURIES AND DISEASES OE S1'ECL\E 0R(;ANS



Online LibraryT. Pickering (Thomas Pickering) PickSurgery → online text (page 121 of 160)