Types and Figures of Trusses

Cross-body type of trusses (eight figures) Chase type of trusses (eight figures)... Hood type of trusses (Twelve figures). Unclassified trusses (four figures). Double trusses (ten figures). Trusses for femoral hernia (sixteen figures Infant umbilical trusses (nine figures)... Adult umbilical trusses (eighteen figure Trusses for ventral hernia (six figures T43-144 1145-146 394-395 Diaceans (original drawing) showing formation of femoral hernia, extra-peritoneal fat and lipoma. ++ 300 —— ABDOMINAL HERNIA ITs DIAGNOSIS AND TREATMENT. CHAPTER IL INTRODUCTION. Definition.—Hernia is the protrusion from a cavity, of any of its natural contents; as hernia of the brain from the cranial cavity, or hernia of the lung from the cavity of the chest. Abdominal hernia is, therefore, the protrusion through the retaining wall of any of the enclosed viscera. This gen- erally occurs at some point in the muscular wall that is weak- ened by the transmission of nerves and blood vessels, at points congenitally defective, or through muscular parts that have been previously lacerated or incised. The word “ Rupture,” so commonly used to denote a con- dition of hernia, will be, as far as possible, avoided in this work, as it leads to an erroneous impression of what actually occurs. In the early ages this term was applied under the supposition that there was actual rupture of the peri- toneum. It is now well known that there is rarely laceration of tissue. Hernia results, in almost every instance, from the gradual stretching of tissue and escape of the abdominal con- tents, either into a preformed (congenital) sac, or by the formation of a sac (acquired) from the peritoneal lining of the abdomen. Abdominal hernize derive their names from the part of the abdominal wall through which they pass. The terms inguinal, femoral, or umbilical, denote at once their place of 2 17 18 ABDOMINAL HERNIA. escape, the exception to this being ventral hernia, which may occur at any point in the anterior abdominal wall other than in the regions named. As ventral hernia occurs at points in the muscular wall so strong as ordinarily to resist hernial protru- sion, it follows that when it does occur, it is either due to some congenital defect or is the result of some injury, such as a stab wound or a cutting operation. Extreme distension of the abdomen may also result in such separation of its aponeurotic fibres as to allow of protrusion. A little more than 73 per cent. of all herniz are of the inguinal type. Next in frequency is femoral hernia, with 18 per cent., and third, umbilical hernia with about 8% per cent. This leaves about 1 per cent. for all of the rarer forms. The individual may have a single hernia or multiple herniz. It is not uncommon to find inguinal and umbilical, or inguinal and femoral herniz in the same subject. The type, or form, of hernia is notably influenced by sex, as shown by the following comparison: Male: Inguinal, 96.33 per cent.; femoral, 2.53 per cent. ; umbilical, 1.14 per cent. Female: Inguinal, 50 per cent.; femoral, 33.15 per cent. ; umbilical, 15.9 per cent. That age has a decided influence on the occurrence of hernia is shown by the exhaustive studies of Paul Berger. His tables show 19.6 cases to 1,000 individuals in the first year of life, and drops to 4.2 .per 1,000 in the second year; then there is a gradual decline up to the twentieth year when only 0.88 is found. From this time on to the seventy-fifth year the in- crease of proportion is constant, reaching at this age its highest point, 24.20 per 1,000 individuals. Hernia consists of the sac and its contents; the sac being formed from peritoneum, the lining membrane of the ab- dominal cavity. It may be formed at the time of the first pro- trusion and is then termed an acquired sac. As will be demon- strated later, a congenital sac may have existed long before the protrusion of the hernia, by the persistence of a pouch of INTRODUCTION. 19 peritoneum (Tunica Vaginalis) which normally should have been obliterated at, or shortly after, birth. The sac consists of its body, or the expanded portion, which contains the bulk of the protrusion; the neck, which is the constricted part running through the muscular wall; and its mouth, the aperture of communication with the peritoneal cavity. The acquired sac on first protruding, may be free from adhesions, and reducible, but readily becomes attached to sur- rounding tissues and from that time is irreducible. It then fur- nishes a permanent, moist, serous lining to the canal through which it protrudes. Hernia of the bladder, of the cecum and sigmoid flexure, may occur without a true hernial sac. The anterior bladder wall is not covered by peritoneum, and it may form the actual protrusion in inguinal hernia. If the protrusion is of fairly large size, it will also drag that part of the organ into the canal that is covered by peritoneum, when both bladder and ab- dominal contents will be found. This same condition exists in sigmoid and cecal hernia, except that in these the peritoneum covers the anterior wall of the gut and the posterior wall is dragged down without this covering. Following previous operations where the peritoneum has for some reason failed to unite, there may be protrusion imme- diately beneath the skin without sac formation. This is most frequently met with in ventral hernia following laparotomy, but I have found in one instance this condition existing in a recurrent inguinal hernia. It was quite evident that the previous operator had either failed to ligate the neck of the sac properly, or what is more likely, the ligature had slipped off, and both omentum and intestine were in contact with scrotal tissue. The contents of a sac may be either omentum, intestine, or in fact any of the movable contents of the abdomen. In some rare cases even those organs that are not ordinarily considered movable, as the kidney or a part of the liver, have been 20 ABDOMINAL HERNIA. found in the hernial sac. The contents of a sac may be freely reducible, or its reduction may be prevented by the great size of the mass and the smallness of the neck of the sac, or from adhesions of the protruding mass to the inner sides of the sac; also by the formation of fibrous bands which transverse the sac in different directions. Omentum and small intestine are most frequently found in the hernial sac; next in frequency, in about the order named, will be found the sigmoid flexure, cecum and transverse colon. The bladder may also protrude into an inguinal hernia sac, but is more frequently found without peritoneal covering. The term enterocele refers to hernia, the contents of which is exclusively intestine, epiplocele to one containing omentum, and the use of the words combined, as entero-epiplocele, to one containing both intestine and omentum. While these are in some instances convenient terms, they wili be avoided in this work on the ground that multiplicity of names adds to the con- fusion of the subject. SURGICAL ANATOMY OF THE INGUINAL REGION. The lower lateral third of the abdominal wall, known as the inguinal region, is an irregularly shaped triangle. Roughly, its outer boundary is Poupart’s ligament, its inner boundary the median line of the body, and its upper boundary an im- aginary transverse line from the crest of the ilium to the median line. The anatomy of this triangle, although the region is comparatively small and easy of access, has proven one of the most difficult to comprehend and teach of any con- nected with the muscular system. The author assumes that his reader has already acquired an anatomical education from works upon the subject and from practical demonstration upon the cadaver, therefore, the anatomy here given is merely to refresh his mental picture of the parts. If the picture is presented from a different view to SURGICAL ANATOMY. QL that which he is accustomed, and minus some of its technical details, it may be even clearer in outline, in which case the object sought will have been fully accomplished. Immediately beneath the skin of this region we come upon the two layers of superficial fascia. These layers contain a deposit of fat of variable thickness according to the condition Fic. 1. Showing position of superficial vessels (size exaggerated). 1, Superficial branch of ex- ternal pudic artery. 2, Superficial epigastric artery. Both are in deep layer of superficial fascia and are divided in hernia operations. 3, Circumflex iliac artery. Not usually divided, of the patient. In operating it will happen many times that the dividing line between the two layers is not discovered, but occasionally it is so well defined as to mislead the operator into the belief that he has already reached the aponeurosis of the external oblique muscle. The only surgical importance connected with this fascia is that the deep layer contains two sets of vessels that are usually cut in the first incision in hernia operations (fig. 1). 22 ABDOMINAL HERNIA. These arteries both come from the femoral space and are first, the superficial epigastric, crossing Poupart’s ligament at its middle third and passing on upwards over the internal ring towards the umbilicus. Second, a superficial branch of the external pudic, leaving the femoral space and passing up di- rectly over the external abdominal ring, and arching over to Fic. 2. Aponcurosis of external oblique muscle, in which is shown the external ring covered by the intercolumnar fascia, the root of the penis. These vessels are not important in size hut may require ligation at time of operation. Beneath this fascia we find the aponeurosis of the external oblique muscle which is easily distinguished by ‘its glistening surface and from the fact that its fibres run obliquely down- ward towards the public bone (fig. 2). In operations for hernia the fleshy part of the external oblique muscle is seldom IRGICAL ANATOMY. 23 seen. The fibres of the aponeurosis are bound together by the overlying infercolummar fascia, which is tendonous in char- acter and furnishes strong protection to the upper angle of the external abdominal ring, by arching across from one pillar to another. In opening down to the external abdominal ring, it frequently obscures the upper angle of that aperture and pre- vents the easy passage of the director under the aponeurosis, until it has been scraped away with some blunt instrument. The cord receives this fascia as its last covering as it comes out between the pillars of the external ring. The aponeurosis of the external oblique muscle is a thin, but very tough, inelastic tendon, which splits easily in the direction of the fibres, especially after the intercolumnar fascia is cut, but furnishes one of the most important parts of the retaining wall of the abdomen. At its lower border it is re- flected back under the abdominal wall forming Poupart’s liga- ment. This lower portion of the aponeurosis is attached to the anterior superior iliac spine above, and to the spine of the pubes below. Just above the pubic attachment there is a split in the fibres for the transmission of the spermatic cord in the male and round ligament in the female. This aperture is called the external abdominal ring. The term “ ”” an unfortunate one, conveys the idea of a circular opening, when in reality it This name, however, has from long is triangular in shape. use become so firmly fixed in the medical mind that it would probably result in even more confusion to adopt any other. The base of this triangular opening is formed by the crest of the pubic bone, and its upper angle is prevented from splitting still higher in the aponeurosis by the intercolumnar fascia. The sides of the triangle are formed by the free split borders of the aponeurosis and are called the pillars of the ring. The ex- ternal, lower pillar, curves around in such a manner as to form a groove upon which the cord rests. The infernal, superior pillar, passes over the cord to the crest of the pubic bone, to interlace in the median line with its fellow of the opposite side. On account of the cord being larger than the round liga- 24 ABDOMINAL HERNIA ment, and to the fact that the testicle passes down through this opening, the external abdominal ring is considerably larger in the male than in the female. Poupart’s ligament, extending from the iliac spine to the spine of the pubes, is also attached to the pubic bone at the pectineal line for about one inch, forming Gimbernat’s liga- Fic. 3. Aponeurosis opened to internal ring, showing lower border of internal oblique muscle; transversalis fascia in deep wall of canal. -ment. The crural arch, beneath which emerges the femoral ves- sels, is formed by Poupart’s ligament, internal oblique and transversalis muscles (figs. 3 and 4). All works on anatomy show these muscles, as shown in the accompanying cuts, nicely dissected one from the other. No such picture is presented on the operating table and for this reason the two muscles will be spoken of together. The lower border of the internal oblique SURGICAL ANATOMY. g x is attached to the outer half of Poupart’s ligament, and the transversalis is attached to the same ligament immediately beneath it, but only to the outer third. The fibres of both muscles are fleshy in character and arch up over the cord, the a o-20 voz A, Symphysis pubis. B, Anterior superior spinous process of crest of ilium. C, Muscular part of external oblique muscle. 2, Linea alba. /, £, External abdominal rings. ZZ, Poupart's ligament. .V, Aponeurosis of external oblique muscle cut open to show deeper parts. 0, Internal oblique muscle. This is turned up at lower edge to show (P) Transversalis muscle. (In operative work these muscles are seen as one.) (2, Trans- versalis fascia. &, Internal abdominal ring. S, Epigastric artery. ¢, , 4 Spermatic cord. ue inguinal hernia leaves the abdomen at R, (Internal ring), and follows the cord to external ring). Direct hernia protrudes directly through the wall at # Femoral hernia protrudes at I. (From Sir Astley Cooper on Hernia.) transversalis even higher than the internal oblique, and then the two muscles becoming blended into an aponeurotic structure, the conjoined tendon, pass down back of the cord and find insertion in the pectineal line of the os pubis. Here conjoined 26 ABDOMINAL HERNIA. tendon is exactly back of the external abdominal ring, and should furnish the most important barrier against the occur- rence of direct inguinal hernia. Some of the fibres pass towards the median line where it joins its fellow of the opposite side. The lower edges of these muscles are indistinguishable on the operating table, and are treated as one structure. Normally, the fibres of these muscles start from Poupart’s ligament in front of the cord, and arching over close to it, descend back of the cord to the pubic bone. In many people this arch is abnormally high, and the insertion of the conjoined tendon is well towards the median line, leaving the muscular wall back of the cord very deficient throughout the whole length of the inguinal canal. At the time of descent of the testicle, through the canal, there is a covering taken from the lower edge of the internal oblique muscle which develops some muscular fibres, and is afterwards known as the cremaster muscle. This fascia, or muscle, frequently forms one of the coverings of a hernial sac. The muscle receives its blood supply from the cremasteric artery, a branch of the epigastric, and its nerve supply from the genital branch of the genito-crural nerve. Neither of these are ordinarily seen in operations for hernia. When the aponeurosis of the external oblique muscle is first split and retracted, so that the canal is freely exposed, the ilio-inguinal nerve will usually be seen following closely the lower border of the internal oblique muscle. The ilio-hypo- stric nerve will also frequently be seen a little higher on the surface of the same muscle. The rectus muscle should, perhaps, be mentioned here on account of its relation to the aponeuroses of the muscles just considered. The apdneuroses of all of the abdominal muscles below the umbilicus pass in front of the recti, leaving the posterior surface of the latter in contact with the transversalis fascia. The muscle is attached below to the pubic crest as far out as the pubic spine and doubtless affords some protection to the external abdominal ring.