CHAPTER XLI
DIAGNOSIS OF ABDOMINAL HERNIA
The diagnosis of a hernia consists (1) in recognizing that a given swelling is a hernia ; in determining (2) the exact situation and anatomical variety of the hernia, (3) the nature of the contents of the hernia, and (4) its pathological condition.
The phenomena of hernia vary so much in difier- ent cases that there are only three features common to it in all conditions. These are (a) the presence of a tumour ; (&) its connexion with the abdominal cavity ; and (c) the sudden or gradual appearance of the tumour as a protrusion from the belly. In the great majority of cases we find the tumour at one or other of the favourite seats of hernia, and learn that it is or has formerly been reducible, with reappearance of the tumour under effort or strain, and we are able by the characteristic feel of the tumour, by tympanitic percussion, or by a gurgle in it, to demonstrate that its contents are one or other of the abdominal viscera, and, by an impulse on cough- ing, that it communicates with the abdominal cavity.
Aualomical vaiieties of hernia All scrotal
and labial hernias descending from the groin are inguinal. A hernia occupying the fold of the groin may be either inguinal or femoral. Abduct the thigh and make the adductor longus tense, and then run the finger up along it, to the pubic spine; if, now, this point of bone is internal to the hernia it
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SURGICAL DIAGNOSIS [chap.
is a femoral hernia ; if external, an inguinal hernia. In the case of a man, the surgeon should pass his forefinger from the bottom of the scrotum up along the cord to the external abdominal ring, when he wiU be able to feel whether the tumour protrudes through that opening or not. If the hernia is felt distinctly below Poupart's ligament (ligamentum inguinale) it is femoral.
A small hernia lying in the inguinal canal is called a bubonocele. A hernia at or close to the umbilicus is known as an umbilical heruia : when congenital the protrusion is through the umbilical orifice ; in later life the " ring " is often an aper- ture in the linea alba close to this. A hernia pro- truding at any other part of the abdominal wall is known as ventral ; this occurs at the seat of old cicatrices or muscular ruptiu-es, and differs from other hernise in having no " neck " to the sac.
Should a hernial tumour be found below Poupart's ligament (ligamentum inguinale), to the inner side of the femoral vessels and deep among the adductor muscles, it is an obturator hernia. It is rare for this variety of hernia to form a distinct tumour ; there may be nothing but a slight sense of resistance deep down beneath the pectineus muscle, with tenderness on pressure at this spot, and pain along the course of the obturator nerve. A careful examination of the inner aspect of the obturator ring should be made from the rectum or vagina. Other rare forms of hernia are vaginal, lumbar, pudendal, ■perineal, ischiatic, and femoral hernia external to the femoral vessels.
Varieties oi iiiguiual hernia.— The following varieties of inguinal hernia are met with : —
- Congenital hernia, or hernia into the tunica vaginalis, characterized by the sudden appearance of a hernia which completely envelops the testicle.
XLi] ABDOMINAL HERNIA 593
Funicular hernia is a hernia into tlie unobliter- ated upper portion of the funicular process. The tumour appears suddenly and may reach to the top of the testicle but does not surromid it. Even when the hernia is large the testicle can be felt below it and quite separate from it.
Acquired hernia, recognized by its appearance first in the groin, then spreading slowly along the cord into the scrotum, where it lies in front of the testicle but does not envelop it. This form may be (a) indirect or oblique if the hernia protrudes through the internal abdominal ring, recognized by its appearance first in the inguinal canal and by observing that after reduction the protrusion on coughing is felt by a finger invaginated into the canal, at the outer end of the canal ; (6) direct if the hernia protrudes through one of the inguinal fossae on either side of the obliterated hypogastric artery — in this case the hernia is felt to protrude immediately behind the external abdominal ring. Either of these is called "incomplete" if it does not extend through the external ring, and " com* pletc " when it does.
An oblique hernia, when old and large, drags inwards the internal ring and comes to resemble clinically a direct hernia. Congenital and funicular hernias are always oblique.
The name interstitial is given to cases of inguinal hernia in which the sac spreads out either beneath or more rarely, superficial to the aponeurosis of the external oblique, forming a tumour above the fold of the groin extending externally to the site o£ the internal ring. This condition is almost always associated witii an undescended testicle on the same side.
The terms " congenital " and " acquired " are
594 SURGICAL DIAGNOSIS [chap.
misleading, as it is known that in the great majority of so-called acquired hernias the sac is preformed.
Contents oi a hernia. — If a hernia is tympanitic on percussion, smooth, rounded, and elastic, has a distinct impulse on coughing, or pelds a gurgle on manipulation, it is an enlerocele, i.e. contains intestine. When it is dull on percussion, firm, lobulated, and does not gurgle, and has only a slight impulse on coughing, it is an efiplocele, i.e. contaius omentum. If in places it is tympanitic on percus- sion and soft and gurgling, but in others firm and lobulated, it is an entero-epiplocele. When a hernia fluctuates throughout, there is a hydrocele of the her- ' i nial sac. When part of a scrotal hernia is found to fluctuate, and on pressure urine is evacuated or the patient experiences a strong desire to mictm-ate, the surgeon may diagnose a cystocele, that is, a hernia containing a part of the bladder. This form of hernia is rare in the male, and quickly becomes ] " irreducible " ; in the female, under the form of j a vaginal protrusion, it is more common. When a femoral hernia in a female contains a small ovoid solid body which is irreducible, tender on palpation, and becomes painful during the menstrual period, it is an ovary in the sac. This must not be con- ' fused with the localized deposit of extraperitoneal fat often found over femoral hernial sacs.
Reference may here be made to the diagnosis of umbilical epiplocele, which has to be distinguished from a subcutaneous lipoma and an outgrowth of subperitoneal fat. All alike consist of soft, rounded, lobulated masses of fat. If the tumour is freely movable in the belly-wall, quite irreducible, and without an expansile impulse, it is a subcKtancovs lipoma. If the tumour on its deep aspect is fixed to the belly wall, is not and never has been reducible,
xLi] ABDOMINAL HERNIA 595
aud has no expansile impulse on coughing, it is a subperitoneal lipoma. If the tumour is fixed deeply to the belly-wall, is or has once been reducible wholly or in part, and has an expansile impulse on coughing, it is an epiplocele. In some cases it is impossible to distinguish between the last two tumours without operation.
Pathological vai-ieties oi hernia. — 1. If the hernial tumour entirely disappears on lying down or on gentle taxis, slipping up into the abdomen and remaining lost there, redescending on coughing or on assuming the vertical position, it is a reducible hernia. After reduction the surgeon may feel the sac of a hernia as a more or less marked thickening of the part, and also the canal or ring through which the hernia has passed, but he should not be able to feel any tumour or special resistance within the abdomen. If on emptying the external hernial sac a tumour or sense of resistance is felt in the adjacent part of the abdomen, it shows that there is a double sac — " hernie en bisac."
Supposing the hernia or any part of it is not thus completely reducible, the surgeon should learn the age of the hernia, how long it has been unreduced, whether it is now larger than usual, and, if so, whether that increased size is the result of a strain or effort, or is quite spontaneous. He should examine the tumour, noticing its tension, outline, and sensitive- ness, whether there is any impulse on coughing, or fluctuation, and whether it is dull or resonant on percussion. He should inquire when a motion was last passed, and whether flatus has been passed since ; if vomiting has occurred he shoiUd examine the vomited matter to estimate from what part of the alimentary canal it has been regurgitated, and he should also learn the frequency of the vomiting ^
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SURGICAL DIAGNOSIS
[chap.
and examine the belly for distension and tenderness. Finally, he should investigate the patient's general condition, his facies, pulse, temperature, tongue, and urine.
If the hernial tumour is not tense and is free from all signs of inflammation, and has an impulse on coughing, and there are no signs of intestinal obstruction, it is a simple irreducible hernia.
If there has been a sudden formation of a hernial tumour, or a sudden enlargement of. an old hernia from some strain or effort, and if the tumour is tense, irreducible by gentle taxis, and there is no impulse on coughing, the hernia is strangulated. It is YQYj important to remember that the acuteness of the symptoms of strangulation of a hernia varies within wide limits ; there may be hardly any pain or tenderness, or this may be quite severe, the pain being referred to the umbilical region. The signs of intestinal obstruction may come on slowly, or may be well marked from the onset, the bowels being absolutely confined, neither flatus nor ffeces pass- ing, vomiting being early, frequent, and s©on ster- coraceous, and attended by collapse. Tension of the tumour, irreducibility, and loss of expansile imjDulse on coughing are invariable signs of strangu- lation. When the parts around the strangulated hernia become swollen, purplish, and oBdematous, and the vomiting ceases and is replaced by hic- cough, the patient becoming cold, Uvid, and very collapsed, gangrene of the hertiia is to be diagnosed. Should a patient Avith an unrelieved strangulation suddenly complain of acute pain in the belly, and the collapse be notably increased, and this is quickly followed by distension of the belly, pain in the back, and great abdomirial tenderness, rupture of intestine and acute peritonitis must be diagnosed.
XLl]
ABDOMINAL HERNIA
597
A small, teusc, irreducible femoral or obturator hernia associated with passage of fteces and flatus is Richler's hernia, in which only a part of the circumference of the bowel is engaged in the hernia. The local features are those of a strangulated hernia, but the signs of complete obstruction are wanting. This form of hernia is not very rare, but the typical symptoms are very seldom met with. Meckel's diverticulum when strangulated may give the same combination of symptoms as Richter's hernia.
If an irreducible hernia has suddenly become larger, is heavy and full, but is tympanitic on per- cussion and gurgles when manipulated, and if the surgeon finds that there is but slight, if any, tender- ness and no marked collapse, only a sense of fullness of the belly, with nausea and vomiting when food is taken, it is an obstructed or incarcerated hernia. There is usually a history of constipation, or of a large and indigestible meal, and, although the bowels are confined, flatus is passed, and there is usually a slight impulse on coughing to be detected in the hernia. This condition is met with most often in large irreducible hernias, either umbilical or in the left groin, and in patients who are careless about the regular action of the bowels.
Whenever a hernial tumour shows signs of inflammation (redness, swelling, local heat, pain and tenderness, with fever), it is an inflamed hernia. This may be due to local or general peritonitis set up by injury or appendicitis, to obstruction, or even to strangulation and gangrene of the contents of the sac ; in all cases the cause of the inflammation must be ascertained.
Efi'ccts of (axis ok" a slraiujulalcil hernia. — When during taxis a hernial tumour yields with a sudden slip and a gurgle, and the contents pass
598 SURGICAL DIAGNOSIS
into the beUy and leave the canal clear (except for the presence of the sac), and there is no unusual re- sistance or swelling to he felt above or adjacent to the canal, the surgeon may be satisfied that the hernia is reduced.
False reduction is of three forms : (1) emptying an external pouch or sac into an internal pouch or sac in " hernie en bisac " ; (2) rupture of the sac and displacement of the contents through the rent in the sac ; (3) displacement of the sac and its contents — reduction en bloc.
Should the hernia yield gradually, go up bodily without a gurgle, and leave the ring unusually free (no sac being in it), the surgeon must suspect reduc- tion en bloc ; and if, on pressing his finger well up into the canal, or examining the part either through the abdominal wall or from the rectum or vagina, a tumour or sense of resistance is met with, and if the symptoms of strangulation persist, this diagnosis becomes established. Reduction en bloc may be very easily effected, even by the patient himself.
If, in attempting to reduce a hernia which has been some time strangled, the tumour yields under the fingers but does not disappear, and the outline and tension of the parts are altered, while at the same time the patient becomes more collapsed, the surgeon is to diagnose rupture of the intestine.
Symptoms of peritonitis coming on or persist- ing after satisfactory reduction of a strangulated hernia indicate either (a) a perforation of the intes- tine following ulceration at the point of constric- tion, or (6) gangrene of a coil of mtestine without perforation.