Part 30 (1/2)
[Ill.u.s.tration: Abdomen and s.c.r.o.t.u.m, showing bone, blood vessels and other internal organs.]
Plate 40--Figure 2.
PLATE 40, Fig. 3.--Hydrocele of the isolated tunica v.a.g.i.n.alis.--When the serous spermatic tube, 6 b, 6 c, becomes obliterated, according to the normal rule, after the descent of the t.e.s.t.i.c.l.e, 7, the tunica v.a.g.i.n.alis, 6 d, is then a distinct serous sac. If a hydrocele form in this sac, it may be distinguished from the congenital variety by its remaining undiminished in bulk when the subject a.s.sumes the horizontal position, or when pressure is made on the tumour, for its contents cannot now be forced into the abdomen. The t.e.s.t.i.c.l.e, 7, holds the same position in this as it does in the congenital hydrocele. [Footnote] The radical cure may be performed here without endangering the peritonaeal sac.
Congenital hydrocele is of a cylindrical shape; and this is mentioned as distinguis.h.i.+ng it from isolated hydrocele of the tunica v.a.g.i.n.alis, which is pyriform; but this mark will fail when the cord is at the same time distended, as it may be, in the latter form of the complaint.
[Footnote: When a hydrocele is interposed between the eye and a strong light, the testis appears as an opaque body at the back of the tunica v.a.g.i.n.alis. But this position of the organ is, from several causes, liable to vary. The testis may have become morbidly adherent to the front wall of the serous sac, in which case the hydrocele will distend the sac laterally. Or the testis may be so transposed in the s.c.r.o.t.u.m, that, whilst the gland occupies its front part, the distended tunica v.a.g.i.n.alis is turned behind. The tunica v.a.g.i.n.alis, like the serous spermatic tube, may, in consequence of inflammatory fibrinous effusion, become sacculated-multilocular, in which case, if a hydrocele form, the position of the testis will vary accordingly.--See Sir Astley Cooper's work, (”Anatomy and Diseases of the Testis;”) Morton's ”Surgical Anatomy;” Mr. Curling's ”Treatise on Diseases of the Testis;” and also his article ”t.e.s.t.i.c.l.e,” in the Cyclopaedia of Anatomy and Physiology.]
[Ill.u.s.tration: Abdomen and s.c.r.o.t.u.m, showing bone, blood vessels and other internal organs.]
Plate 40--Figure 3.
PLATE 40, Fig. 4.--The serous spermatic tube remaining pervious, a congenital hernia is formed.--When the t.e.s.t.i.c.l.e, 7, has descended to the s.c.r.o.t.u.m, if the communication between the peritonaeum, 6 a, and the tunica v.a.g.i.n.alis, 6 c, be not obliterated, a fold of the intestine, 13, will follow the t.e.s.t.i.c.l.e, and occupy the cavity of the tunica v.a.g.i.n.alis, 6 d. In this form of hernia (hernia tunicae v.a.g.i.n.alis, Cooper), the intestine is in front of, and in immediate contact with, the t.e.s.t.i.c.l.e.
The intestine may descend lower than the t.e.s.t.i.c.l.e, and envelope this organ so completely as to render its position very obscure to the touch.
This form of hernia is named congenital, since it occurs in the same condition of the parts as is found in congenital hydrocele--viz., the inguinal ring remaining unclosed. It may occur at any period of life, so long as the original congenital defect remains. It may be distinguished from hydrocele by its want of transparency and fluctuation. The impulse which is communicated to the hand applied to the s.c.r.o.t.u.m of a person affected with scrotal hernia, when he is made to cough, is also felt in the case of congenital hydrocele. But in hydrocele of the separate tunica v.a.g.i.n.alis, such impulse is not perceived. Congenital hernia and hydrocele may co-exist; and, in this case, the diagnostic signs which are proper to each, when occurring separately, will be so mingled as to render the precise nature of the case obscure.
[Ill.u.s.tration: Abdomen and s.c.r.o.t.u.m, showing bone, blood vessels and other internal organs.]
Plate 40--Figure 4.
PLATE 40, Fig. 5.--Infantile hernia.--When the serous spermatic tube becomes merely closed, or obliterated at the inguinal ring, 6 b, the lower part of it, 6 c, is pervious, and communicating with the tunica v.a.g.i.n.alis, 6 d. In consequence of the closure of the tube at the inguinal ring, if a hernia now occur, it cannot enter the tunica v.a.g.i.n.alis, and come into actual contact with the t.e.s.t.i.c.l.e. The hernia, 13, therefore, when about to force the peritonaeum, 6 a, near the closed ring, 6 b, takes a distinct sac or investment from this membrane. This hernial sac, 6 e, will vary as to its position in regard to the tunica v.a.g.i.n.alis, 6 d, according to the place whereat it dilates the peritonaeum at the ring. The peculiarity of this hernia, as distinguished from the congenital form, is owing to the s.c.r.o.t.u.m containing two sacs,--the tunica v.a.g.i.n.alis and the proper sac of the hernia; whereas, in the congenital variety, the tunica v.a.g.i.n.alis itself becomes the hernial sac by a direct reception of the naked intestine. If in infantile hernia a hydrocele should form in the tunica v.a.g.i.n.alis, the fluid will also distend the pervious serous spermatic tube, 6 c, as far up as the closed internal ring, 6 b, and will thus invest and obscure the descending herniary sac, 13. This form of hernia is named infantile (Hey), owing to the congenital defect in that process, whereby the serous tube lining the cord is normally obliterated. Such a form of hernia may occur at the adult age for the first time, but it is still the consequence of original default.
[Ill.u.s.tration: Abdomen and s.c.r.o.t.u.m, showing bone, blood vessels and other internal organs.]
Plate 40--Figure 5.
PLATE 40, Fig. 6.--Oblique inguinal hernia in the adult.--This variety of hernia occurs not in consequence of any congenital defect, except inasmuch as the natural weakness of the inguinal wall opposite the internal ring may be attributed to this cause. The serous spermatic tube has been normally obliterated for its whole length between the internal ring and the tunica v.a.g.i.n.alis; but the fibrous tube, or spermatic fascia, is open at the internal ring where it joins the transversalis fascia, and remains pervious as far down as the t.e.s.t.i.c.l.e. The intestine, 13, forces and distends the upper end of the closed serous tube; and as this is now wholly obliterated, the herniary sac, 6 c, derived anew from the inguinal peritonaeum, enters the fibrous tube, or sheath of the cord, and descends it as far as the tunica v.a.g.i.n.alis, 6 d, but does not enter this sac, as it is already closed. When we compare this hernia, Fig. 6, Plate 40, with the infantile variety, Fig. 5, Plate 40, we find that they agree in so far as the intestinal sac is distinct from the tunica v.a.g.i.n.alis; whereas the difference between them is caused by the fact of the serous cord remaining in part pervious in the infantile hernia; and on comparing Fig. 6, Plate 40, with the congenital variety, Fig. 4, Plate 40, we see that the intestine has acquired a new sac in the former, whereas, in the latter, the intestine has entered the tunica v.a.g.i.n.alis. The variable position of the t.e.s.t.i.c.l.e in Figs. 4, 5, & 6, Plate 40, is owing to the variety in the anatomical circ.u.mstances under which these herniae have happened.
[Ill.u.s.tration: Abdomen and s.c.r.o.t.u.m, showing bone, blood vessels and other internal organs.]
Plate 40--Figure 6.
COMMENTARY ON PLATES 41 & 42.
DEMONSTRATIONS OF THE ORIGIN AND PROGRESS OF INGUINAL HERNIAE IN GENERAL.
PLATE 41, Fig. 1.--When the serous spermatic tube is obliterated for its whole length between the internal ring, 1, and the top of the t.e.s.t.i.c.l.e, 13, a hernia, in order to enter the inguinal ca.n.a.l, 1, 4, must either rupture the peritonaeum at the point 1, or dilate this membrane before it in the form of a sac. [Footnote] If the peritonaeum at the point 1 be ruptured by the intestine, this latter will enter the fibrous spermatic tube, 2, 3, and will pa.s.s along this tube devoid of the serous sac. If, on the other hand, the intestine dilates the serous membrane at the point, 1, where it stretches across the internal ring, it will, on entering the fibrous tube, (infundibuliform fascia,) be found invested by a sac of the peritonaeum, which it dilates and pouches before itself.
As the epigastric artery, 9, bends in general along the internal border of the ring of the fibrous tube, 2, 2, the neck of the hernial sac which enters the ring at a point external to the artery must be external to it, and remain so despite all further changes in the form, position, and dimensions of the hernia. And as this hernia enters the ring at a point anterior to the spermatic vessels, its neck must be anterior to them.
Again, if the bowel be invested by a serous sac, formed of the peritonaeum at the point 1, the neck of such sac must intervene between the protruding bowel and the epigastric and spermatic vessels. But if the intestine enter the ring of the fibrous tube, 2, 2, by having ruptured the peritonaeum at the point 1, then the naked intestine will lie in immediate contact with these vessels.
[Footnote: Mr. Lawrence (op. cit.) remarks, ”When we consider the texture of the peritonaeum, and the mode of its connexion to the abdominal parietes, we cannot fancy the possibility of tearing the membrane by any att.i.tude or motion.” Cloquet and Scarpa have also expressed themselves to the effect, that the peritonaeum suffers a gradual distention before the protruding bowel.]
[Ill.u.s.tration: Abdomen, showing bone, blood vessels and other internal organs.]