Surgical Anatomy Part 28

Plate 34

COMMENTARY ON PLATES 35, 36, 37, & 38.

THE DISTINCTIVE DIAGNOSIS BETWEEN EXTERNAL AND INTERNAL INGUINAL HERNIAE, THE TAXIS, THE SEAT OF STRICTURE, AND THE OPERATION.

A comparison of the relative position of these two varieties of herniae is in ordinary cases the chief means by which we can determine their distinctive diagnosis; but oftentimes they are found to exhibit such an interchange of characters, that the name direct or oblique can no longer serve to distinguish between them. The nearer the one approaches the usual place of the other, the more likely are they to be mistaken the one for the other. An internal hernia may enter the inguinal ca.n.a.l, and become oblique; while an external hernia, though occupying the ca.n.a.l, may become direct. It is only when these herniae occur at the situations commonly described, and where they manifest their broadest contrast, that the following diagnostic signs can be observed.

The external bubonocele, H, Plate 37, G, Plate 38, when recently formed, may be detected at a situation midway between the iliac and pubic spinous processes, where it has entered the internal ring. When the hernia extends itself from this part, its course will be obliquely inwards, corresponding with the direction of the inguinal ca.n.a.l. While it still occupies the ca.n.a.l without pa.s.sing through the external ring, it is rendered obscure by the restraint of the external oblique tendon; but yet a degree of fulness may be felt in this situation. When the hernia has pa.s.sed the external ring, T, Plate 36, it dilates considerably, and a.s.sumes the form of an oblong swelling, H, Plate 36, behind which the spermatic vessels are situated. When it has become scrotal, the cord will be found still on its posterior aspect, while the t.e.s.t.i.c.l.e itself occupies a situation directly below the swelling.

The internal hernia, H, Plate 38, also traverses the external ring, T, where it a.s.sumes a globular shape, and sometimes projects so far inwards, over the p.u.b.es, C, as to conceal the crista of this bone. As the direction of this hernia is immediately from behind forwards, the inguinal ca.n.a.l near the internal ring is found empty, unswollen. The cord, Q, lies external to and somewhat over the fore part of this hernia; and the t.e.s.t.i.c.l.e does not occupy a situation exactly beneath the fundus of the sac, (as it does in the external hernia,) but is found to be placed either at its fore part or its outer side. This difference as to the relative position of the cord and t.e.s.t.i.c.l.e in both these forms of herniae, is accounted for under the supposition that whilst the external variety descends inside the sheaths of the inguinal ca.n.a.l, the internal variety does not. But this statement cannot apply to all cases of internal hernia, for this also occasionally enters the ca.n.a.l. Both forms of inguinal herniae may exist at the same time on the same side: the external, G, Plate 38, being a bubonocele, still occupying the inguinal ca.n.a.l; while the internal, H, protrudes through the external ring, T, in the usual way. In this form of hernia--a compound of the oblique and direct--while the parts remain still covered by the integuments, it must be difficult to tell its nature, or to distinguish any mark by which to diagnose the case from one of the external variety, H, Plate 36, which, on entering the ca.n.a.l at the internal ring, protrudes at the external ring. In both cases, the swelling produced in the groin must be exactly of the same size and shape. The epigastric artery in the case where the two herniae co-exist lies between them, holding in its usual position with respect to each when occurring separately--that is, on the outer side of the internal hernia, H, and on the inner side of the external one, G; and the external hernia, G, not having descended the ca.n.a.l as far as the external ring, T, allows the internal hernia, H, to a.s.sume its usual position with respect to the cord, Q. [Footnote]

[Footnote: Cases of this double hernia (external and internal) have been met with by Wilmer, Arnaud, Sandifort, Richter, and others. A plurality of the same variety of hernia may also occur on the same side. A complete and incomplete external inguinal hernia existing in the one groin, is recorded by Mr. Aston Key in his edition of Sir Astley Cooper's work on Hernia. Sir Astley Cooper states his having met with three internal inguinal herniae in each inguinal region. (Ing. et Congenit. Hernire.) ]

Returning, however, to the more frequent conditions of inguinal hernia--viz., those in which either the direct or the oblique variety occurs alone--it should be remembered that a hernia originally oblique, H, Plates 35 and 37, may, when of long standing, and having attained a large size, destroy, by its gravitation, the obliquity of the inguinal ca.n.a.l to such a degree as to bring the internal, H, Plate 35, opposite to the external ring, as at I, and thereby exhibit all the appearance of a hernia originally direct, I, Plate 37. In such a case, the epigastric artery, F, which lies on the outer side of the neck of a truly direct hernia, I, Plate 37, will be found to course on the inner side, G, of the neck of this false-seeming direct hernia, I, Plate 35.

In the trial made for replacing the protruded bowel by the taxis, two circ.u.mstances should be remembered in order to facilitate this object: 1st, the abdominal parietes should be relaxed by supporting the trunk forward, and at the same time flexing the thigh on the trunk; 2nd, as every complete hernial protrusion becomes distended more or less beyond the seat of stricture--wherever this may happen to be--its reduction by the taxis should be attempted, with gradual, gentle, equable pressure, so that the sac may be first emptied of its fluid. That part of the hernia which protruded last should be replaced first. The direction in which the hernia protrudes must always determine the direction in which it is to be reduced. If it be the external or oblique variety, the viscus is to be pushed upwards, outwards, and backwards; if it be the internal or direct variety, it is to be reduced by pressure, made upwards and backwards. Pressure made in this latter direction will serve for the reduction of that hernia which, from being originally external and oblique, has a.s.sumed the usual position of the internal or direct variety.

The seat of the stricture in an external inguinal hernia is found to be situated either at the internal ring, corresponding to the neck of the sac, or at the external ring. Between these two points, which "bound the ca.n.a.l," and which are to be regarded merely as pa.s.sive agents in causing stricture of the protruding bowel, the lower parts of the transversalis and internal oblique muscles embrace the herniary sac, and are known at times to be the cause of its active strangulation or spasm.

The seat of stricture in an internal hernia may be either at the neck of its sac, I, Plate 37, or at the external ring, T, Plate 38; and according to the locality where this hernia enters the inguinal wall, the nature of its stricture will vary. If the hernia pa.s.s through a cleft in the conjoined tendon, f, Plate 38, this structure will constrict its neck all around. If it pa.s.s on the outer margin of this tendon, then the neck of the sac, bending inwards in order to gain the external ring, will be constricted against the sharp resisting edge of the tendon. Again, if the hernia enter the inguinal wall close to the epigastric artery, it will find its way into the inguinal ca.n.a.l, become invested by the structures forming this part, and here it may suffer active constriction from the muscular fibres of the transverse and internal oblique or their cremasteric parts. The external ring may be considered as always causing some degree of pressure on the hernia which pa.s.ses through it.

In both kinds of inguinal herniae, the neck of the sac is described as being occasionally the seat of stricture, and it certainly is so; but never from a cause originating in itself per se, or independently of adjacent structures. The form of the sac of a hernia is influenced by the parts through which it pa.s.ses, or which it pushes and elongates before itself. Its neck, H, Plate 37, is narrow at the internal ring of the fascia transversalis, because this ring is itself narrowed; it is again narrowed at the external ring, T, Plate 36, from the same cause.

The neck of the sac of a direct hernia, I, Plate 37, being formed in the s.p.a.ce of the separated fibres of the conjoined tendon, or the pubic part of the transversalis fascia, while the sac itself pa.s.ses through the resisting tendinous external ring, is equal to the capacities of these outlets. But if these constricting outlets did not exist, the neck of the sac would be also wanting. When, however, the neck of the sac has existed in the embrace of these constricting parts for a considerable period--when it suffers inflammation and undergoes chronic thickening--then, even though we liberate the stricture of the internal ring or the external, the neck of the sac will be found to maintain its narrow diameter, and to have become itself a real seat of stricture. It is in cases of this latter kind of stricture that experience has demonstrated the necessity of opening the sac (a proceeding otherwise not only needless, but objectionable) and dividing its constricted neck.

The fact that the stricture may be seated in the neck of the sac independent of the internal ring, and also that the duplicature of the contained bowel may be adherent to the neck or other part of the interior, or that firm bands of false membrane may exist so as to constrict the bowel within the sac, are circ.u.mstances which require that this should be opened, and the state of its contained parts examined, prior to the replacement of the bowel in the abdomen. If the bowel were adherent to the neck of the sac, we might, when trying to reduce it by the taxis, produce visceral inv.a.g.i.n.ation; or while the stricture is in the neck of the sac, if we were to return this and its contents en ma.s.se (the "reduction en bloc") into the abdomen, it is obvious that the bowel would be still in a state of strangulation, though free of the internal ring or other opening in the inguinal wall.

The operation for the division of the stricture by the knife is conducted in the following way: an incision is to be made through the integuments, adipous membrane, and superficial fascia, of a length and depth sufficient to expose the tendon of the external oblique muscle for an inch or so above the external ring; and the hernia for the same extent below the ring. The length of the incision will require to be varied according to circ.u.mstances, but its direction should be oblique with that of the hernia itself, and also over the centre of its longitudinal axis, so as to avoid injuring the spermatic vessels. If the constriction of the hernia be caused by the external ring, a director is to be inserted beneath this part, and a few of its fibres divided. But when the stricture is produced by either of the muscles which lie beneath the aponeurosis of the external oblique, it will be necessary to divide this part in order to expose and incise them.

When the thickened and indurated neck of the sac is felt to be the cause of the strangulation, or when the bowel cannot be replaced, in consequence of adhesions which it may have contracted with some part of the sac, it then becomes necessary to open this envelope. And now the position of the epigastric artery is to be remembered, so as to avoid wounding it in the incision about to be made through the constricted neck of the sac. The artery being situated on the inner side of the neck of the sac of an oblique hernia, requires the incision to be made outwards from the external side of the neck; whereas in the direct hernia, the artery being on its outer side, the incision should be conducted inwards from the inner side of the neck. But as the external or oblique hernia may by its weight, in process of time, gravitate so far inwards as to a.s.sume the position and appearance of a hernia originally direct and internal, and as by this change of place the oblique hernia, becoming direct as to position, does not at the same time become internal in respect to the epigastric artery,--for this vessel, F, Plate 35, has been borne inwards to the place, G, where it still lies, internal to the neck of the sac, and since, moreover, it is very difficult to diagnose a case of this kind with positive certainty, it is therefore recommended to incise the stricture at the neck of the sac in a line carried directly upwards. (Sir Astley Cooper.) It will be seen, however, on referring to Plates 32, 33, 34, 35, 36, 37, & 38, that an incision carried obliquely upwards towards the umbilicus would be much more likely to avoid the epigastric artery through all its varying relations.

DESCRIPTION OF THE FIGURES OF PLATES 35, 36, 37, & 38.

PLATE 35.

A. Anterior superior spine of the ilium; a, indicates the situation of the middle of Poupart's ligament.

B. Symphysis pubis.

C. Rectus abdominis muscle covered by the fascia transversalis.

D. The peritonaeum lining the groin.

E. The situation of the conjoined tendon resisting the further progress of the external hernia gravitating inwards.

F. A dotted line indicating the original situation of the epigastric artery in the external hernia.

G. The new position a.s.sumed by the epigastric artery borne inwards by the weight of the old external hernia.

H. The original situation of the neck of the sac of the external hernia.

I. The new situation a.s.sumed by the neck of the sac of an old external hernia which has gravitated inwards from its original place at H.

K. The external iliac vein covered by the peritonaeum.

L. The external iliac artery covered by the peritonaeum and crossed by the spermatic vessels.

M. The psoas muscle supporting the spermatic vessels and the genito-crural nerve.

N. The iliacus muscle.

O. The transversalis fascia lining the transverse muscle.

[Ill.u.s.tration: Abdomen, showing bone, blood vessels, muscles and other internal organs.]

Plate 35

PLATE 36.--AN ANTERIOR VIEW OF PLATE 35.

A. Anterior superior iliac spinous process.

B. The navel.

C. The situation of the crista pubis.

D. The external oblique muscle; d, its tendon.

E. Internal oblique muscle; e, its tendon, covering the rectus muscle.

F. Lower part of the transverse muscle; f, the conjoined tendon.

G. The transversalis fascia investing the upper part of the hernial sac; g, the original situation of the epigastric artery internal to this hernia; g*, the new situation of the artery pushed inwards.

H. The hernial sac, invested by h, the elongation of the fascia transversalis, or funnel-shaped sheath.

I. The femoral artery.

K. The femoral vein.

L. The sartorius muscle.

M. Iliac part of the fascia lata joining Poupart's ligament.

N. Pubic part of the fascia lata.