Adhesions in hernial sac. Scarpa. (Lejars.)
Thus viewed, then, what are the relations of traumatism to congenital defects? When thus explained they seem to be as follows: By no means every individual who sustains an injury to the abdomen suffers from hernia, but when the parts are already weakened or prepared by the preëxistence of these congenital defects, then a small amount of strain or injury may serve to open them up and to produce a condition apparently due to accident which otherwise could not have occurred. The more I have studied the entire question the more I have come to the conclusion that hernias of the ordinary type, save in case of extreme violence, would not occur were it not for such a congenital prearrangement and tissue permission, as it were; so that we are justified in assuming that inguinal and femoral like umbilical hernias are really of congenital origin.
The Signs of Hernia.
—The signs of hernia include the existence of a tumor, usually at one of the common outlets, which may be variable in size, and fixed, changeable, or otherwise, according to whether it consist of intestine or omentum. To a hernial protrusion consisting of intestine alone may still be given the old term enterocele. One consisting of omentum is known as epiplocele. Hernial protrusions may attain tremendous dimensions, especially those appearing at the umbilicus, and some of these sacs contain perhaps the larger proportion of the intestine or even of the entire abdominal contents. Scrotal tumors, again, may attain large size, e. g., that of the individual’s head or even much larger. According to the nature of the contents such a tumor will be more or less resonant on percussion, and more or less compressible as well as reducible. Reducibility—namely, the ability to be returned to the abdominal cavity—is the most characteristic feature of a hernia and one possessed by nearly every such tumor, at least at its inception. It may, however, be lost.
Loss of reducibility, when occurring gradually, is replaced by what is known as incarceration, i. e., more or less complete fixation, at the same time without such pressure on bloodvessels as to produce necrosis. Incarceration may be the result of reduction in caliber of the hernial outlet, or of the formation of adhesions between the walls of the sac and its contents, such adhesions being common alike to omentum and large or small bowel. (See [Fig. 599].) Strangulation is an acute process which may terminate either a reducible or an incarcerated hernia. It implies some sudden change, such as overcrowding of the bowel within the sac, or some peculiar kinking, by which intestinal caliber is shut off, as well as blood supply affected because of pressure, by which the vitality of the gut and of the sac is compromised or perhaps quickly lost. Strangulation, then, includes at least the possibilities and usually the simultaneous occurrence of acute obstruction of the bowel with more or less gangrene of the sac itself, as well as of the compromised gut.
Reducibility as an ordinary feature of hernia is one with which the patient himself is quite familiar, most patients with reducible hernias being able to effect reduction in the horizontal position, accompanied by some manipulation or maneuver. When in such cases reduction cannot be accomplished incarceration or perhaps strangulation has begun and the case immediately assumes serious proportions. Reduction is usually accompanied by a peculiar gurgle, as well as disappearance of the tumor itself, while the opening through which it has disappeared can usually be identified with the finger, by invagination of the scrotum, or by pressure over the femoral region. Such a tumor usually reappears when the patient stands, or particularly when he coughs or makes any straining effort, and the occurrence and recurrence of these phenomena clearly establish the diagnosis of hernia.
Irreducible or incarcerated hernias usually give some impulse upon the patient’s coughing, as do the reducible forms, yet in some cases they lead to more difficulty of diagnosis. Ordinarily in the male the question is mainly as between inguinal (or scrotal) hernia and hydrocele. In the latter there is a pear-shaped tumor whose apex should be found below the level of the inguinal outlet; a tumor which will fluctuate, whose shape does not change, which gives no impulse when the patient coughs, which is not influenced by pressure, even with the patient in the horizontal position. It is only in incarcerated or in peculiar types of congenital hernias, or in those combined, as they may be, with hydrocele, in which doubt should not be easily dissipated. While incarceration predisposes to acute obstruction it is not always followed by it, but may produce a more chronic type of constipation, with tendency to fecal impaction, because of the mechanical impediment to freedom of bowel motility. This condition is more frequently met in the aged.
Inflammation of the hernial sac, as well as of its coverings, leads to a condition described as inflamed hernia. It is essentially one of circumscribed cellulitis. It may be due to the irritation of a badly fitting truss or to other external causes. The inflammation may extend so as to involve the sac wall itself, and thus produce adhesions and later incarceration, or it may set up actual peritonitis, which may extend to the general abdominal cavity and terminate fatally. The more superficial and less acute forms are scarcely distinguishable from a local erysipelas which may terminate by abscess. Such a condition might be mistaken for one of suppurating bubo. Nevertheless the existence of the hernia itself should guard one against this error and make him extremely cautious in using the knife, even though it be necessary for the evacuation of pus.
Fig. 600