7ol 



HERNIA: 



hernia just described may exist in two different 

 conditions ; one, in which it is still lodged within 

 the inguinal canal, and appears in the form of a 

 tumour in the upper part of the groin, termed 

 bubonocele ; the other, in which it has escaped 

 through the external ring, and having dropped 

 down constitutes scrotal hernia. 



When the rupture has descended no farther 

 than the groin, there are but two affections that 

 can bear any resemblance to it : these are, the 

 testis itself whilst in the act of descending, if 

 this process has been delayed beyond the usual 

 period of life, and an enlarged inguinal gland. 

 However possible in cases of crural hernia (as 

 shall be noticed hereafter), a mistake of the 

 latter description is not likely to occur in the 

 disease under consideration, but there is an ob- 

 servation of Mr. Colles on this subject de- 

 serving of attention. "I do not suppose," 

 says this distinguished professor, " that any 

 surgeon of competent anatomical knowledge 

 could mistake it for inflammation of those 

 lymphatic glands which lie in the fold of the 

 groin, but an enlargement, whether from a 

 venereal or any other cause, of two lymphatic 

 glands which lie on the side of the abdomen, as 

 high up but rather more internally than the in- 

 ternal abdominal ring; an enlargement of these 

 glands will produce appearances resembling 

 those of inguinal hernia."* 



It seems almost surprising how the descent 

 of the testicle could possibly be mistaken for 

 a hernia when the mere examination of the 

 scrotum would throw such an explanatory light 

 upon the subject, but a consideration of the 

 following circumstances will be useful in solving 

 the difficulty. 1st, The detention of the tes- 

 ticle within the abdomen until an unusually 

 late period is by no means so infrequent an oc- 

 currence as is generally supposed even by sur- 

 geons in considerable practice : I have heard a 

 military medical officer observe on the great 

 number of young men that had passed before 

 him for inspection after enlistment, in whom one 

 and sometimes both the testes had not de- 

 scended. 2d, The symptoms of both affections 

 bear a general though not necessarily a close 

 resemblance ; for the situation of the" tumour 

 is exactly the same, and if the testicle is com- 

 pressed and inflamed, the pain and tenderness 

 and the inflammatory fever are to a certain ex- 

 tent like the symptoms of strangulation. But 

 I have not met the same costiveness, at least 

 the same obstinate resistance of the bowels to 

 the operation of aperient medicines, nor the 

 same vomiting, nor the same exquisite tender- 

 ness spreading over the abdomen, and the pulse 

 is not that small, thready, hard, and rapid vi- 

 bration that is produced by peritoneal inflam- 

 mation. In one case I perceived that pressure 

 on the tumour occasioned that sickening pain 

 and sensation of faintness which a slight injury 

 of the testicle so often produces; and I imagine 

 that in this case a light and very gentle per- 

 cussion might prove a useful auxiliary dia- 

 gnostic. But, 3rd, it does not always happen 



* Colles's Surgical Anatomy, p. 46. 



that the surgeon takes sufficient pains to inves- 

 tigate the disease before him. "He is apt," 

 says Mr. Colles,* " at once to set down the case 

 as incarcerated hernia, a complaint with which 

 he is familiar, and does not suspect the exist- 

 ence of a disease which is to him perhaps ex- 

 tremely rare. Boys sometimes indulge in the 

 trick of forcing up the testicles into the ab- 

 domen, which may be followed by unhappy 

 consequences, for the gland may not descend 

 again, or if it does, perhaps a portion of in- 

 testine slips down along with and behind it, 

 which may then become strangulated, while its 

 presence is unsuspected and the symptoms 

 attributed to compression of the testis." A boy, 

 about seven years of age, had forced the left 

 testicle into the abdomen : ten years afterwards, 

 the inguinal ring having probably become un- 

 usually contracted, the testicle passed under the 

 femoral arch with all the symptoms of stran- 

 gulated hernia, on account of which he was 

 obliged to undergo the operation .-j- 



When the hernia has become scrotal, it then 

 comes more to resemble diseases of the testis 

 and of the cord, but in general these are very 

 easily distinguished, and there are only three 

 that could lead a practitioner into error, and 

 then only through unpardonable carelessness ; 

 the hydrocele of the tunica vaginalis testis, 

 the hydrocele of the spermatic cord, and the 

 varicocele or a varicose condition of the veins 

 of the cord. 



There is not much likelihood that hydrocele 

 of the tunica vaginalis could, in its earlier 

 stages, be mistaken for hernia: it commences 

 below and increases in an upward direction, 

 while a hernia proceeds from above downwards; 

 and at first in cases of hydrocele, the ring, the 

 cord, and all these parts can be accurately felt. 

 As the disease proceeds and the water reaches 

 the ring, a diagnosis is not so easy; still in 

 almost every case of rupture the testis and the 

 cord, particularly the former, can be easily felt 

 lying behind and at the bottom of the tumour, 

 which is not the case in hydrocele. Besides, 

 hydrocele is lighter as to weight ; it gives a 

 sensation of fluctuation to the touch ; it never 

 exhibits that soft doughy character that belongs 

 to omental hernia : moreover it is diaphanous, 

 and the light of a candle can be seen through 

 it, if the tumour is examined in a darkened 

 room. 



A collection of water within the sheath of 

 the cord must, I should think, be rather an 

 infrequent occurrence ; at least it has not 

 fallen to my lot to meet with many examples 

 of it. Still the practitioner must be aware of 

 the possibility of the disease, and that both 

 from the nature of the accident that occasions 

 it, and many of the accompanying symptoms, it 

 may very readily be mistaken for hernia. A 

 young man fell with his groin against the edge 

 of a tub, and in an incredibly short space of 

 time afterwards a colourless elastic tumour 

 appeared in the usual situation of hernia. 



* Colics, op. citat. 



t Scarpa, op. citat. p. 235. 



