HERNIA. 



hernia, the diagnosis is vastly more difficult, and 

 often the surgeon has to be guided by the gene- 

 ral symptoms of peritoneal inflammation rather 

 than by the results of local examination, how- 

 ever carefully performed. Mr. Colles* states 

 that "this species of hernia is liable to stran- 

 gulation even before it can be felt externally," 

 an observation I was enabled to verify a few 

 months since in a case where a very small 

 knuckle of intestine had not passed the inferior 

 aperture of the femoral canal, but was lodged 

 in an absorbent gland, which seemed to have 

 been hollowed out to receive it.f But the 

 hernia may be much larger and still not disco- 

 verable in consequence of some unfortunate 

 complication : I have seen a case of incarce- 

 rated hernia | in which an abscess was seated 

 at the superior part of the thigh immediately 

 in front of the sac ; and after the pus had been 

 evacuated, some time elapsed before decisive 

 symptoms pointed out the existence of the 

 more formidable disease behind. There is, 

 in the Museum in Park-street, a preparation 

 exhibiting a fatty tumour growing on the exter- 

 nal surface of a hernial sac. The patient from 

 whom it was taken was the subject of opera- 

 tion, and after the integuments and fascia had 

 been divided and this tumour presented, some 

 doubts were at first entertained as to the pre- 

 sence of a hernia beneath it ; but on careful 

 examination the operator discovered the hernial 

 tumour, and cutting cautiously through the 

 other, opened the sac, in which a knuckle of 

 intestine was found incarcerated. The opera- 

 tion was successful, and the patient recovered. 

 "In many instances," says Mr. Colles, "the 

 difficulty of discriminating the disease is consi- 

 derably increased by an enlarged lymphatic 

 g'and lying anterior to a very small hernia." 



Perhaps there are no two affections more 

 liable to be mistaken for each other than crural 

 hernia and an enlarged lymphatic gland; and 

 however apparently distinct the two affections 

 may be, and however easy it may seem to form 

 a diagnosis in theory, still the best surgeons 

 speak of the difficulty of discriminating between 

 them, and many acknowledge having fallen 

 into the error themselves. It has happened 

 that a patient has had a hernia on one side and 

 an enlarged gland on the other, and when 

 symptoms of strangulation became urgent, it 

 was the gland that was considered to be the 

 most pressing, and it was selected for the opera- 

 tion. I recollect two cases which occurred 

 nearly at the same time ; one in which there 

 was a very minute hernia at the left groin, 

 which had been regarded as a swelled gland, 

 and the patient died of the effects of its stran- 

 gulation ; the other a case of pure peritoneal 

 inflammation, in which the patient happened to 

 have a swollen gland in the groin, which was 

 actually cut down upon and exposed, but the 

 operation did not much injury, for the patient 



* Op. citat. p. 83. 



t This curious case occurred in the Meath Hospi- 

 tal in the summer of 1835. 



J I use this term in the sense hitherto employed, 

 not implying perfect strangulation. 



subsequently recovered. It has been said that 

 a diagnosis can be established by attention to 

 the following circumstances. The hernia fol- 

 lows on some sudden exertion, on a blow or a 

 fall, and appears suddenly and at once ; 

 whereas the gland in the commencement is- 

 very small, perhaps like a moveable kernel, 

 and increases slowly and by degrees. Besides, 

 this diagnostic will be greatly assisted if there 

 is a chancre or other sore to account for the irri- 

 tation and inflammation of the gland; but on 

 the other hand the hernia does not always 

 assume its given size at once, it is often 

 so small at the beginning that the patient is not 

 aware of its existence, and so far from appear- 

 ing suddenly after a violent exertion it may 

 have been present for months without being 

 perceived. The hernia receives an impulse 

 from coughing or sneezing, and retires or be- 

 comes smaller in the recumbent posture, which 

 are not observed to happen with the gland ; but 

 then an enlarged gland may be complicated 

 with a hernia, and the symptoms so mixed and 

 confused that a diagnosis may be very difficult. 

 It is said that a gland maybe moved about and 

 withdrawn from its situation in a slight degree, 

 and if it can there is no great danger of mis- 

 taking it ; but when it has arrived at the size or 

 occupies the place which could make it resem- 

 ble a hernia, then it does not admit of being 

 moved under the fascia, and the diagnosis is 

 almost impossible. Fortunately, a crural hernia 

 does not often consist of omen turn, but when it 

 does there is nothing more likely to exhibit the 

 characters of a gland in a state of chronic dis- 

 ease, and I know not how the two cases can be 

 accurately distinguished. Here the physical 

 evidence derived from a gentle percussion (as 

 already noticed) is utterly and completely 

 valueless. 



Lumbar or psoas abscess is another affection 

 that may be confounded with femoral hernia, 

 and Mr. Colles states that he had known the 

 mistake to have been committed. These diseases 

 resemble each other in the following circum- 

 stances. Both present very nearly in the same 

 situation at the bend of the groin, are firm and 

 elastic; coughing gives to each the same or a 

 similar impulse; and there are cases on record 

 in which psoas abscess disappeared under pres- 

 sure or by the patient assuming the recumbent 

 posture. Yet I think the two cases not very 

 difficult of distinction. Psoas abscess is a dis- 

 ease of youth; it does not often occur in the 

 adult except as a critical abscess after fever, or 

 in connexion with caries and curvature of the 

 spine, in either of which cases the collateral 

 circumstances will point it out ; whereas femoral 

 hernia is the disease of married women, and of 

 course will not be likely to occur at the same 

 period of life with the abscess. A sense of 

 fluctuation is generally perceptible in psoas 

 abscess; not so with hernia. The abscess is 

 preceded by pain and weight in the loins and 

 by shivering. It is a scrofulous complaint, and 

 there will probably be other indications of the 

 diathesis, such as the transparent skin, the 

 thickened upper lip, or perhaps ill-conditioned 

 sears about the neck. Any of these symptoms 



