Surgical Anatomy Part 30

[Ill.u.s.tration: Abdomen and s.c.r.o.t.u.m, showing bone, blood vessels and other internal organs.]

Plate 40--Figure 2.

PLATE 40, Fig. 3.--Hydrocele of the isolated tunica v.a.g.i.n.alis.--When the serous spermatic tube, 6 b, 6 c, becomes obliterated, according to the normal rule, after the descent of the t.e.s.t.i.c.l.e, 7, the tunica v.a.g.i.n.alis, 6 d, is then a distinct serous sac. If a hydrocele form in this sac, it may be distinguished from the congenital variety by its remaining undiminished in bulk when the subject a.s.sumes the horizontal position, or when pressure is made on the tumour, for its contents cannot now be forced into the abdomen. The t.e.s.t.i.c.l.e, 7, holds the same position in this as it does in the congenital hydrocele. [Footnote] The radical cure may be performed here without endangering the peritonaeal sac.

Congenital hydrocele is of a cylindrical shape; and this is mentioned as distinguis.h.i.+ng it from isolated hydrocele of the tunica v.a.g.i.n.alis, which is pyriform; but this mark will fail when the cord is at the same time distended, as it may be, in the latter form of the complaint.

[Footnote: When a hydrocele is interposed between the eye and a strong light, the testis appears as an opaque body at the back of the tunica v.a.g.i.n.alis. But this position of the organ is, from several causes, liable to vary. The testis may have become morbidly adherent to the front wall of the serous sac, in which case the hydrocele will distend the sac laterally. Or the testis may be so transposed in the s.c.r.o.t.u.m, that, whilst the gland occupies its front part, the distended tunica v.a.g.i.n.alis is turned behind. The tunica v.a.g.i.n.alis, like the serous spermatic tube, may, in consequence of inflammatory fibrinous effusion, become sacculated-multilocular, in which case, if a hydrocele form, the position of the testis will vary accordingly.--See Sir Astley Cooper's work, ("Anatomy and Diseases of the Testis;") Morton's "Surgical Anatomy;" Mr. Curling's "Treatise on Diseases of the Testis;" and also his article "t.e.s.t.i.c.l.e," in the Cyclopaedia of Anatomy and Physiology.]

[Ill.u.s.tration: Abdomen and s.c.r.o.t.u.m, showing bone, blood vessels and other internal organs.]

Plate 40--Figure 3.

PLATE 40, Fig. 4.--The serous spermatic tube remaining pervious, a congenital hernia is formed.--When the t.e.s.t.i.c.l.e, 7, has descended to the s.c.r.o.t.u.m, if the communication between the peritonaeum, 6 a, and the tunica v.a.g.i.n.alis, 6 c, be not obliterated, a fold of the intestine, 13, will follow the t.e.s.t.i.c.l.e, and occupy the cavity of the tunica v.a.g.i.n.alis, 6 d. In this form of hernia (hernia tunicae v.a.g.i.n.alis, Cooper), the intestine is in front of, and in immediate contact with, the t.e.s.t.i.c.l.e.

The intestine may descend lower than the t.e.s.t.i.c.l.e, and envelope this organ so completely as to render its position very obscure to the touch.

This form of hernia is named congenital, since it occurs in the same condition of the parts as is found in congenital hydrocele--viz., the inguinal ring remaining unclosed. It may occur at any period of life, so long as the original congenital defect remains. It may be distinguished from hydrocele by its want of transparency and fluctuation. The impulse which is communicated to the hand applied to the s.c.r.o.t.u.m of a person affected with scrotal hernia, when he is made to cough, is also felt in the case of congenital hydrocele. But in hydrocele of the separate tunica v.a.g.i.n.alis, such impulse is not perceived. Congenital hernia and hydrocele may co-exist; and, in this case, the diagnostic signs which are proper to each, when occurring separately, will be so mingled as to render the precise nature of the case obscure.

[Ill.u.s.tration: Abdomen and s.c.r.o.t.u.m, showing bone, blood vessels and other internal organs.]

Plate 40--Figure 4.

PLATE 40, Fig. 5.--Infantile hernia.--When the serous spermatic tube becomes merely closed, or obliterated at the inguinal ring, 6 b, the lower part of it, 6 c, is pervious, and communicating with the tunica v.a.g.i.n.alis, 6 d. In consequence of the closure of the tube at the inguinal ring, if a hernia now occur, it cannot enter the tunica v.a.g.i.n.alis, and come into actual contact with the t.e.s.t.i.c.l.e. The hernia, 13, therefore, when about to force the peritonaeum, 6 a, near the closed ring, 6 b, takes a distinct sac or investment from this membrane. This hernial sac, 6 e, will vary as to its position in regard to the tunica v.a.g.i.n.alis, 6 d, according to the place whereat it dilates the peritonaeum at the ring. The peculiarity of this hernia, as distinguished from the congenital form, is owing to the s.c.r.o.t.u.m containing two sacs,--the tunica v.a.g.i.n.alis and the proper sac of the hernia; whereas, in the congenital variety, the tunica v.a.g.i.n.alis itself becomes the hernial sac by a direct reception of the naked intestine. If in infantile hernia a hydrocele should form in the tunica v.a.g.i.n.alis, the fluid will also distend the pervious serous spermatic tube, 6 c, as far up as the closed internal ring, 6 b, and will thus invest and obscure the descending herniary sac, 13. This form of hernia is named infantile (Hey), owing to the congenital defect in that process, whereby the serous tube lining the cord is normally obliterated. Such a form of hernia may occur at the adult age for the first time, but it is still the consequence of original default.

[Ill.u.s.tration: Abdomen and s.c.r.o.t.u.m, showing bone, blood vessels and other internal organs.]

Plate 40--Figure 5.

PLATE 40, Fig. 6.--Oblique inguinal hernia in the adult.--This variety of hernia occurs not in consequence of any congenital defect, except inasmuch as the natural weakness of the inguinal wall opposite the internal ring may be attributed to this cause. The serous spermatic tube has been normally obliterated for its whole length between the internal ring and the tunica v.a.g.i.n.alis; but the fibrous tube, or spermatic fascia, is open at the internal ring where it joins the transversalis fascia, and remains pervious as far down as the t.e.s.t.i.c.l.e. The intestine, 13, forces and distends the upper end of the closed serous tube; and as this is now wholly obliterated, the herniary sac, 6 c, derived anew from the inguinal peritonaeum, enters the fibrous tube, or sheath of the cord, and descends it as far as the tunica v.a.g.i.n.alis, 6 d, but does not enter this sac, as it is already closed. When we compare this hernia, Fig. 6, Plate 40, with the infantile variety, Fig. 5, Plate 40, we find that they agree in so far as the intestinal sac is distinct from the tunica v.a.g.i.n.alis; whereas the difference between them is caused by the fact of the serous cord remaining in part pervious in the infantile hernia; and on comparing Fig. 6, Plate 40, with the congenital variety, Fig. 4, Plate 40, we see that the intestine has acquired a new sac in the former, whereas, in the latter, the intestine has entered the tunica v.a.g.i.n.alis. The variable position of the t.e.s.t.i.c.l.e in Figs. 4, 5, & 6, Plate 40, is owing to the variety in the anatomical circ.u.mstances under which these herniae have happened.

[Ill.u.s.tration: Abdomen and s.c.r.o.t.u.m, showing bone, blood vessels and other internal organs.]

Plate 40--Figure 6.

COMMENTARY ON PLATES 41 & 42.

DEMONSTRATIONS OF THE ORIGIN AND PROGRESS OF INGUINAL HERNIAE IN GENERAL.

PLATE 41, Fig. 1.--When the serous spermatic tube is obliterated for its whole length between the internal ring, 1, and the top of the t.e.s.t.i.c.l.e, 13, a hernia, in order to enter the inguinal ca.n.a.l, 1, 4, must either rupture the peritonaeum at the point 1, or dilate this membrane before it in the form of a sac. [Footnote] If the peritonaeum at the point 1 be ruptured by the intestine, this latter will enter the fibrous spermatic tube, 2, 3, and will pa.s.s along this tube devoid of the serous sac. If, on the other hand, the intestine dilates the serous membrane at the point, 1, where it stretches across the internal ring, it will, on entering the fibrous tube, (infundibuliform fascia,) be found invested by a sac of the peritonaeum, which it dilates and pouches before itself.

As the epigastric artery, 9, bends in general along the internal border of the ring of the fibrous tube, 2, 2, the neck of the hernial sac which enters the ring at a point external to the artery must be external to it, and remain so despite all further changes in the form, position, and dimensions of the hernia. And as this hernia enters the ring at a point anterior to the spermatic vessels, its neck must be anterior to them.

Again, if the bowel be invested by a serous sac, formed of the peritonaeum at the point 1, the neck of such sac must intervene between the protruding bowel and the epigastric and spermatic vessels. But if the intestine enter the ring of the fibrous tube, 2, 2, by having ruptured the peritonaeum at the point 1, then the naked intestine will lie in immediate contact with these vessels.

[Footnote: Mr. Lawrence (op. cit.) remarks, "When we consider the texture of the peritonaeum, and the mode of its connexion to the abdominal parietes, we cannot fancy the possibility of tearing the membrane by any att.i.tude or motion." Cloquet and Scarpa have also expressed themselves to the effect, that the peritonaeum suffers a gradual distention before the protruding bowel.]

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

Plate 41--Figure 1

PLATE 41, Fig. 2--When the serous spermatic tube, 11, remains pervious between the internal ring, 1, (where it communicates with the general peritonaeal membrane,) and the top of the t.e.s.t.i.c.l.e, (where it opens into the tunica v.a.g.i.n.alis,) the bowel enters this tube directly, without a rupture of the peritonaeum at the point 1. This tube, therefore, becomes one of the investments of the bowel. It is the serous sac, not formed by the protruding bowel, but one already open to receive the bowel. This is the condition necessary to the formation of congenital hernia. This hernia must be one of the external oblique variety, because it enters the open abdominal end of the infantile serous spermatic tube, which is always external to the epigastric artery. Its position in regard to the spermatic vessels is the same as that noticed in Fig, 1, Plate 41. But, as the serous tube through which the congenital hernia descends, still communicates with the tunica v.a.g.i.n.alis, so will this form of hernia enter this tunic, and thereby become different to all other herniae, forasmuch as it will lie in immediate contact with the t.e.s.t.i.c.l.e.

[Footnote]

[Footnote: A hernia may be truly congenital, and yet the intestine may not enter the tunica v.a.g.i.n.alis. Thus, if the serous spermatic tube close only at the top of the t.e.s.t.i.c.l.e, the bowel which traverses the open internal inguinal ring and pervious tube will not enter the tunica v.a.g.i.n.alis.]

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

Plate 41--Figure 2

PLATE 41, Fig. 3.--The infantile serous spermatic tube, 11, sometimes remains pervious in the neighbourhood of the internal ring, 1, and a narrow tapering process of the tube (the ca.n.a.l of Nuck) descends within the fibrous tube, 2, 3, and lies in front of the spermatic vessels and epigastric artery. Before this tube reaches the t.e.s.t.i.c.l.e, it degenerates into a mere filament, and thus the tunica v.a.g.i.n.alis has become separated from it as a distinct sac. When the bowel enters the open abdominal end of the serous tube, this latter becomes the hernial sac. It is not possible to distinguish by any special character a hernia of this nature, when already formed, from one which occurs in the condition of parts proper to Fig. 1, Plate 41, or that which is described in the note to Fig. 2, Plate 41; for when the intestine dilates the tube, 11, into the form of a sac, this latter a.s.sumes the exact shape of the sac, as noticed in Fig. 1, Plate 41. The hernia in question cannot enter the tunica v.a.g.i.n.alis. Its position in regard to the epigastric and spermatic vessels is the same as that mentioned above.

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

Plate 41--Figure 3

PLATE 41, Fig. 4.--If the serous spermatic tube, 11, be obliterated or closed at the internal ring, 1, thus cutting off communication with the general peritonaeal membrane; and if, at the same time, it remain pervious from this point above to the tunica v.a.g.i.n.alis below, then the herniary bowel, when about to protrude at the point 1, must force and dilate the peritonaeum, in order to form its sac anew, as stated of Fig.

1, Plate 41. Such a hernia does not enter either the serous tube or the tunica v.a.g.i.n.alis; but progresses from the point 1, in a distinct sac. In this case, there will be found two sacs--one enclosing the bowel; and another, consisting of the serous spermatic tube, still continuous with the tunica v.a.g.i.n.alis. This original state of the parts may, however, suffer modification in two modes: 1st, if the bowel rupture the peritonaeum at the point 1, it will enter the serous tube 11, and descend through this into the cavity of the tunica v.a.g.i.n.alis, as in the congenital variety. 2nd, if the bowel rupture the peritonaeum near the point 1, and does not enter the serous tube 11, nor the tunica v.a.g.i.n.alis, then the bowel will be found devoid of a proper serous sac, while the serous tube and tunica v.a.g.i.n.alis still exist in communication.

In either case, the hernia will hold the same relative position in regard to the epigastric artery and spermatic vessels, as stated of Fig.

1, Plate 41.

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

Plate 41--Figure 4

PLATE 41, Fig. 5.--Sudden rupture of the peritonaeum at the closed internal serous ring, 1, though certainly not impossible, may yet be stated as the exception to the rule in the formation of an external inguinal hernia. The aphorism, "natura non facit saltus," is here applicable. When the peritonaeum suffers dilatation at the internal ring, 1, it advances gradatim and pari pa.s.su with the progress of the protruding bowel, and a.s.sumes the form, character, position, and dimensions of the inverted curved phases, marked 11, 11, till, from having at first been a very shallow pouch, lying external to the epigastric artery, 9, it advances through the inguinal ca.n.a.l to the external ring, 4, and ultimately traverses this aperture, taking the course of the fibrous tube, 3, down to the t.e.s.t.i.c.l.e in the s.c.r.o.t.u.m.

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

Plate 41--Figure 5

PLATE 41, Fig. 6.--When the bowel dilates the peritonaeum opposite the internal ring, and carries a production of this membrane before it as its sac, then the hernia will occupy the inguinal ca.n.a.l, and become invested by all those structures which form the ca.n.a.l. These structures are severally infundibuliform processes, so fas.h.i.+oned by the original descent of the t.e.s.t.i.c.l.e; and, therefore, as the bowel follows the track of the t.e.s.t.i.c.l.e, it becomes, of course, invested by the selfsame parts in the selfsame manner. Thus, as the infundibuliform fascia, 2, 3, contains the hernia and spermatic vessels, so does the cremaster muscle, extending from the lower margins of the internal oblique and transversalis, invest them also in an infundibuliform manner. [Footnote]

[Footnote: Much difference of opinion prevails as to the true relation which the cord (and consequently the oblique hernia) bears to the lower margins of the oblique and transverse muscles, and their cremasteric prolongation. Mr. Guthrie (Inguinal and Femoral Hernia) has shown that the fibres of the transversalis, as well as those of the internal oblique, are penetrated by the cord. Albinus, Haller, Cloquet, Camper, and Scarpa, record opinions from which it may be gathered that this disposition of the parts is (with some exceptions) general. Sir Astley Cooper describes the lower edge of the transversalis as curved all round the internal ring and cord. From my own observations, coupled with these, I am inclined to the belief that, instead of viewing these facts as isolated and meaningless particulars, we should now fuse them into the one idea expressed by the philosophic Carus, and adopted by Cloquet, that the cremaster is a production of the abdominal muscles, formed mechanically by the t.e.s.t.i.c.l.e, which in its descent dilates, penetrates, and elongates their fibres.]

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

Plate 41--Figure 6

PLATE 41. Fig. 7.--When an external inguinal hernia, 11, dilates and protrudes the peritonaeum from the closed internal ring, 1, and descends the inguinal ca.n.a.l and fibrous tube, 3, 3, it imitates, in most respects, the original descent of the t.e.s.t.i.c.l.e. The difference between both descents attaches alone to the mode in which they become covered by the serous membrane; for the t.e.s.t.i.c.l.e pa.s.ses through the internal ring behind the inguinal peritonaeum, at the same time that it takes a duplicature of this membrane; whereas the bowel encounters this part of the peritonaeum from within, and in this mode becomes invested by it on all sides. This figure also represents the form and relative position of a hernia, as occurring in Figs. 1 and 3, 5, and 6, Plate 41.