—Regarding the cause and nature of the common forms—namely, the inguinal and femoral—I propose here to introduce the views enunciated by Russell, of Melbourne, which seem to me to furnish the actual explanation for nearly all instances. This explanation refers to the congenital origin of the condition, even though it do not appear until the middle years of life. In the case of inguinal hernia it refers also to the persistence of the canal of Nuck, or of at least incomplete obliteration of the original vaginal process or prolongation of the peritoneum, which comes down with the migrating testicle and whose lower portion furnishes the cavity of the tunica vaginalis. It is more rational to explain the occurrence of hernia in connection with this preformed sac than by the view that there are so many instances of congenital weakness of the abdominal wall. That such weakness exists in many cases of hernia is undeniable, but this is to be regarded as the effect rather than the actual condition. From this last statement it follows also that there is great advantage in early operation, and in complete removal of the sac, which when performed early will not only cure the hernia but prevent the weakening of the abdominal wall itself. It follows, further, that the use of a truss, save possibly in the case of young infants, is an improper method of treatment. In other words, upon it is based the crux of the whole matter of successful treatment, i. e., operative removal of the sac.
It will be seen, then, that the cause of inguinal hernia is closely related with the cause of so-called congenital [hydrocele] of the cord (q. v.), the latter condition being one of sacculation of the canal, with accumulation of fluid; and it is interesting to recall that such sacculations are occasionally found in the ordinary so-called congenital hernias, when they are seen early, and before all anatomical surroundings have been merged together. The existence of a hernia implies the presence of a sac, and a congenital defect furnishes this latter, while the variations in the type of hernia are due mainly to the variations in the sac itself, i. e., in its location.
Fig. 597
Congenital hernia.
Fig. 598
Infantile hernia.
Russell has traced out the relations between the peritoneal pouches of the lower abdomen and the principal bloodvessels, and has shown how the former arrange themselves about the latter and are carried with them as they develop, assuming in consequence the type either of inguinal or femoral hernia, according as they are placed to the inner or outer and lower side of the same. He has insisted, and I think properly, that the variations observed in the clinical manifestations of a hernia are mainly determined by the size and the position of the sac, and that these depend upon its relations to the femoral and epigastric vessels, the associated sac and vessel being subject to the same vicissitudes in development. In this way the occurrence at one time of a congenital and at another of a so-called infantile type of inguinal hernia may be easily explained, as well as the differences between the so-called funicular and the partial form, and also the occurrence of the retroperitoneal or properitoneal forms, which, as variations are rare, and as clinical manifestations perplexing, but which nevertheless are easily explained when viewed in this light ([Figs. 597] and [598]).
Fig. 599