EXAMINATION OF A

CASE OF HERNIA
A hernia is defined as protrusion of wh ole or a part of a v iscus th rough th e wall
that contains it. The term can be applied to p ro trusion of a m uscle through its fascia!
coverin g or of brain through fracture of skull or through foramen magnum into the sp inal
canal. But by fa r the commonest va riety of h ernia is protrusion of a viscus or a part
of it through th e abdominal wall and will be d iscussed h ere.
Of the abdomina l he rniae th e common varieties are inguinal, fem ora l, u mbilical,
incision al and epigastric, w hile the rare varieties a re obtura tor, lu mbar, gluteal and
Spigelian.
lnguinal h ernia comes ou t through the superficial in gu inal ring. Indirect or oblique
inguina l h ernia com es out of the abdominal cavity th rou gh the d eep inguinal ring,
traverses a ll along the inguinal canal and ultimately becomes superficial th rough the
superficial inguinal ring. Direct inguina l he rnia enters the inguinal canal th rough the
medial half of its weak pos terior wall (through the H esselbach 's trian gle) and becomes
superficia l th rough the same s uperficial inguinal ring. Inguinal h ernia is said to be
comp lete when the contents have reached the bottom of the scrotum. Otherwise the hernia
is incomp lete.
Femoral hernia comes ou t th rough the femoral canal and becomes superficial through
the saphenous open ing.
HISTORY.- (i) Age.- indirect inguinal h ernia is us ually m e t with in young
ind iv iduals, wh ereas a d irec t h ernia is mostly seen in older s ubjects.
(ii) Occupatio11.- Strenuous work is responsible for development of hernia. Of
course, there sh ould be associa ted underlying weakness of the abdominal m u scles or
pers is ten ce of p rocessus vaginalis.
COMPLAINTS.- I. Pain. - 1n the beginning when th ere is a ' tendency to hernia'
the pa tient complains of a d ragging and aching type of pain which gets worse as the
day passes. Pa in may appear long before the lump is noticed. It continues so long as
the hernia is progr essing but ceases w hen it is fully formed.
When the hernia becom es very painful and tender, it is probably strangu lated. At
this time the patient may complain of p ain all over th e abdomen due to drag on th e
mesentery or omentum.
2. Lump. - Many herniae may cause no pain and the patient p resents because he
noticed a swelling in the groin. But this is very r are an d some sort of discom for t is
almost a lways p resen t. Th e followings are the set questions to be asked in case of any
inguinoscrotal swelling :
(a) How did it start? - Whether on s trai ning like coughing or lifting weight. Th is
is u su al in case of a h ernia. (b) Wh ere did it first nppenr? lf it be in the groin and
EXAMINATION OF A CASE OF HERNIA 595

gradually extended into the scrotum - it is an inguinal hernia. If it h ad appeared below

the groin crease and gradually ascends above it - the swelling is a femoral hernia .
(c) Whnt wns the size and extent when it wns first seen? If the hernia reaches the bottom
of the scrotum at its first appearance, it is a congenital hernia d eveloped into a
preformed sac. It must be remembered that though it is a congenital hernia it may appear
at any age. In the acquired type the swelling is small to start with and gradually
increases in size. (d) Does it disappear nutomntically on lying down? Direct inguinal hernia
disappears automatically as soon as the patient lies down. Indirect hernia has to be
reduced.
3. Systemic symptoms. - If the h ernia is obstructing the lumen of the bowel
(incarcerated hernia) cardinal symptoms of intes tinal obstruction will appear. They are
colicky abdominal pain, vomiting, abdominal distension and absolute constipation. If the
patient is vomiting, note the character of the vomitus - whether bilious or faecal
smelling. Faecal smelling vomitus heralds ominous sign.
4. Other complaints.- The cause of the hernia must be enquired into. Pers istent
coughing of chronic bronchitis, constipation, frequency of micturition or urgency of
benign enlargement of prostate may be the earlier complaints which the patients
deliberately do not mention cons idering them to be irrelevant. Leading questions may
be asked to find out these complaints.
PAST HISTORY.- Whether the patient had any operation or not? During
appendicectomy d ivision of nerve may lead to weakness of the abdominal muscles at
the inguina l region and a s ubsequent direct inguinal hernia . Many a time the patient

Flg .3 8 .2 .- A direct inguinal hernia may develo p

Fig.38.1.- A typical case of left oblique inguinal as a result of weakness of the abdo minal wall caused
hernia. by division of nerves during appendicecto my.
gives a previous history of hernia repair on the same side (recurrent hernia) or on the
opposite s ide (right sided hernia generally precedes tha t of the left s ide).

LOCAL EXAMINATION
It must be realised that both the inguinal regions must be exposed from the level
of the umbilicus to the mid-thigh level.
596 A MANUAL O CLI NICAL SURGERY

Position of the patient.-Pa tient is firs t examined in the s tanding position a nd then
in the s upine position. Inguinal, femoral, epigastric, obtura lor, lumbar, gluteal and
Spigelian herniae are best examined in the standing position and should not b e omitted.
The patient is asked lo h old the clothes up during examination in the s tanding position.
He must nol bend forwa rd while being examined.
INSPECTION. -
!. Swelling. - If a swelling is already present, note (i) Size & Shape.- An indirect
hernia is pyriform in shape, with a s ta lk a t the externa l inguinal ring. lt usually exten ds
down into the scrotum. A direct h ernia is spherical in shape and s hows little tendency

Fig.38.4 .- In case of inguinal

Fig.38.3.- Looking for an impulse on coughing
while the patient coughs. Note the position of the
patient (standing and that of the examiner - sitting).
hernia, which is even commoner
in case of females, the swelling
lies medial to the pubic tubercle
positioned by the tip of the index
finger.

to enter into the scrotum. Femoral hernia, takes up a spherical shape s tarting from below
and la teral to the pubic tubercle. (ii) Position and Extent.- Inguinal hernia extends from
above the inner part of the inguinal ligament down to the scrotum. Note if the swelling
goes right down to the bottom of th e scrotum (con genita l typ e) or s tops just above the
tes tis (funicular and acquired va rieties). Femoral hernia ex tends from below the inguina l
Iigamen t and ascends over it. (iii) Visible peristalsis.- Tf the covering is thin as in
recurrent h ernia peris talsis may be observed. Vis ible pe ristalsis is never seen in femoral
h ernia. Jn case of inguinal hernia the s tudents should remember that the sc rotal s kin
exhibits movements due to contraction of the d artos.
2. Skin over the swelling.- In uncomplicated hernia the overlying s kin s hould be
norm a l. If the hernia is s trang ula ted the s kin may be reddened . If the patient is using
truss for a long lime, discolou ra tion and s treaks of brow n p igmentation due to deposition
of hacmos idc rin may be seen . The s ubcutaneous tissue may be atrophied, so the skin
may be wrinkled. In case of recurrent hernia scar of previous opera tion w ill be evident.
A wide, irregula r and pu ckered sca r indica tes wound infection followin g previous
operation . This is one of the common causes of recurrence.
1. Jmpulse on cou~hlnA,- The pa tien t is asked to turn his face away from the
cl inicia n and to cough . This is done to avoid the sa li vary sh ower from the pa tient. Look
carefully a t the superficia l inguina l ring. If a swelling alrea dy exis ts, it will expand
EXAMINATION or A CASE OF HERNlA 597

during coughing as more abdominal contents will be driven out into the hernial sac
due to increased abdomina l tension (expansile cough impulse). If a swelling was nol
present a momentary bu lge may be seen synchronously with the act of coughing.
Presence of expansile cough impulse is almost diagnostic of a hernia, but absence of
this s ign does not exclude a diagnosis of hernia. If the neck of the sac is blocked by
adh esions additional viscera w ill not get access into the sac during coughing.
4. Position of the penis. - This is only important in case of inguinal hernia. A large
h ernia in the scrotum will push the penis to the oth e r s ide.
PALPATION.- If a swelling is present it is palpated systematically from in front,
from the side and from behind noting all the points, e.g. temperature, tenderness, s ize
and s hape etc., as discussed in chapter 3 ' Examination of a Swelling'. Only important
points relevant to cases of hernia are discussed below :

Fig.38.5.- The femoral hernia lies lateral

to the pubic tubercle (positioned by the tip
of the index finger) and below the inguinal
ligament. When the hernia enlarges it
travels upwards superficial to the inguinal
ligament as shown by the arrow.
Flg.38.6.- Shows the method
'to get above the swelling'. In a
case of inguinal hernia this is not
possible. It is only possible in a
pure scrotal swelling.

1. Position and Extent. - If the swelling descends into the scrotum or labia majora,
it is obviously an inguinal hernia. When it remains conlined to the g roin, it should be
differentiated from a femoral hernia. Two anatomical structures are considered in this
resp ect - (a) the pubic tubercle and (b) the inguinal ligament. An inguinal hernia is
positioned above the inguinal ligament and medial to the pubic tubercle, whereas a
femoral hernia lies below the inguinal ligament and latera l to the pubic tubercle. But
it mus t be remembered that a la rge femoral hernia ascend s superficial to the inguinal
ligament thou gh its base w il l s till be below the inguinal ligament. In obese patients it
is very difficult to feel the p ubic tubercle. One may follow the tendon of adductor longus
upwards to reach the pubic tubercle.
2. To get above the welling (Fig.38.6).- In case of a swelling this is important.
This examination differentiates a scrotal swelling from an inguino-scrotal swelling. The
root of the scrotum is held between the thum b in front an d other fingers behind in an
a ttem pt to reach above the swelling. In case of ing uinal hernia one cannot get above
598 A MANUAL ON CLINICAL SURGERY

the swelling, whereas in case of the pure

Pos.t10n of Sapheoous opening through w hich
Femoral HernJ• becomes supeff1cral
scrotal swelling one can feel nothing
between the fingers except the structures
within the spermatic cord. In case of
femoral hernia this examination is of no
use as femoral hernia does not give rise
to a scrotal swelling.
3. Consistency.- The swelling feels
doughy and granular if the hernia
contains omentum (omentocele o r
epiplocele). It is elastic if it contains
intestine (enterocele). A s trangulated
hernia feels tense and tender. This is of

I great importance in diagnosing this

Fig.38.7 .- Diagrammatic representation showing
the relative positions of inguinal hernia and femoral
hernia in respect to pubic tubercle. The superficial
inguinal ring is placed above and medial to the
pubic tubercle. The saphenous opening is situated 4
C m
below and lateral to pubic tubercle.
testis can be felt apart from the hernia .
condition.
4. Relation of the swelling to the
testis and spermatic cord.- Inguina l hernia
remains in front and sides of the
spermatic cord and testis which remain
incorporated in the swelling. Cf the hernia
is acquired or of funicular variety the
hernia stops just above the testis. So the

.··.
.

Fig.38.8 .- lnguinoscrotal swelling Fig.38.9.- Shows the method of palpation

caused by an infantile hydrocele. for impulse on coughing.

TWO CLASSICAL SIGNS OF AN UNCOMPLICATED HERNIA ARE (i) IMPULSE ON COUGHING

AND (ii) REDUCIBILITY.
5. Impulse on coughing (Fig.38.9) .- This examination should always be performed
in standing position of the patient. When there is no swelling a finger is placed on
the s uperficial inguina l ring and the patient is asked to cough. The root of the scrotum
can also be h eld between the index finger and the thumb and felt for impulse on
EXAMINATION OF A CASE OF HERNIA 599

Fig.38. 10. - An incomplete

-
indirect left inguinal hernia.

coughing. Contents of hernia Fig.38.11. - Zieman's technique is shown in which the index finger
is placed on the deep inguinal ring (to detect bulge of the indirect
w ill force out th rough the
inguinal hernia when the patient coughs), the middle finger is placed
superficial inguinal ring and on the superficial inguinal ring (to detect bulge of the direct inguinal
separate the thumb and the hernia when the patient coughs) and the ring finger is placed on the
index finger. This is an saphenous opening (to detect bulge of the femoral hernia when the
expansile impulse. Impulse on pat ient coughs). Th e patient is now asked to cough to
coughing will be absent in case diagnose the type of hernia the patient is suffering from.
of strangula ted hernia,
incarcerated hernia and when the neck of the sac becomes blocked by adhesions which prevent
fresh entrance of the contents into the sac. A distinguished method (Fig.38.11) to find out
w hethe r the case is one of direct, indirect (oblique) or femoral hernia is to place the
index finger over th e deep inguina l ring (½ inch above the mid-inguin al point, which
is the midpoint between anterior superior iliac spine and symphysis pubis), th e middle
finger over the superficial ingu inal ring and the ring finger over the saphen ous opening
(4 cm below and lateral to the pubic tubercle). Rem ember this technique (Zieman's
technique) can only be applied w h en there is no obvious swelling or after the hernia
has been comp letely reduced. The patient is asked to hold the nose and blow (this is
better according to Zieman) or to cough. When impulse is felt on the index finger the
case is one of indirect hernia, w h en impulse is felt on the middle finger the case is
one of direct hernia and when it is felt on th e ring finger the case is one of femoral
h ernia.
In presence of swelling, coughing will expand (expan s ile impulse) the swelling and
will increase tension w ithin the swelling. It must be remembered th at movement of the
swelling is n ot a criterion. A localised swelling of the spermatic cord (encysted hydrocele
of the cord) or an undescended testis will sometim es move down the inguinal canal
and may come out through the external opening yet it is not a h ernia. In case of a
large femora l he rnia many a time it is n ot so easy to e licit impulse on coughing. Th e
whole mass is picked up between the thumb and the fingers to get at the root. Now
the patient is asked to cough to palpa te impulse on coughing.
600 A MANUAL ON CLJN1CAL SURGERY

6. Is the swelling reducible?- The patient is first instructed to lie down on the
bed. In many instances the hernia reduces itself when the patient lies down (direct
hernia). You may as k the patient to reduce the hernia
and i.n majority of ca es the patients can reduce it r
aptly. In the rema ining cases the patient is asked to
flex the thigh of the affected side and to adduct and
rotate it internally. This will not only relax the pillars
of the superficial ring but also will relax the oblique
muscles of the abdomen. The fundus of the sac is
gently held with one hand and even pressure is
applied to it to sq ueeze the contents towards and
abdomen while the other hand will guide the contents
through the superficial inguinal ring (Fig. 38.12). This
Fig.38.12.- Shows the method of
is known as 'Taxis'. Taxis mus t be carried out very reducing an inguinal hernia. Note
gently. Rough h andling will bring forth fa tal that the thigh is flexed and internally
complications. Note whether the contents reduce wi th rotated . With one hand the fundus
gurgling. This occurs in an enterocele. In enterocele of the sac is being squeezed while
the first part is often difficult to reduce but the las t with the other hand the hernia is
part s lips in easily. In an omentocele the first part d irected through the superficial
goes in easily w hile the last part resents to be inguinal ring.
reduced.
In case of femoral hernia similar manoeuv re is employed to reduce excep t for the
fact that the contents are reduced through the saphenous opening.
If a hernia cannot be reduced, it is an irreducible hernia or an obstructed h ernia
or a strangulated hernia.
7. Invagination test.- After reduction of the hernia this test may be performed to
palpate the hernial orifice. It is better to perform this test in recumbent position of the
patient. Little finger should be
used to minimise hurting the
p a tient. But if it becomes
inconvenient, one can u se the
index finger. lnvaginate the skin
from the bottom of the scrotum
and the little finger is pushed
up to palpate the pubic tubercle.
Right ha nd should be used for
the right side and left h and for
the left side. The finger is then
rotated and pus hed further up
Figs. 38. 13 & 38. 14. - lnvagination test. Commence
into the s uperficial inguinal ring.
invagination of the skin from the bottom of the scrotum so as The n ail w ill be against the
to get free play of the finger for the second stage of examination. spermatic cord and the pulp will
feel the ring. Utmost gentleness is
required for this examination. Normal ring is a triangular slit which admits only the tip
of a finger. If more than one fin ger can be easily introduced, the ring is abnormally
la rge. But this will not always be associated with hernia. The patient is asked to cough .
EXAMINATION OF A CASE OF HERNIA 60 1

Norma lly the examining fi nger will be squeezed by the approximation of the two pillars.
A palpable imp ulse w ill confirm the diagnosis.
When the finger ente rs the ring -
does it go directly backwards (direct
he rnia) or upwards, backwards and
outwards (ind irect hernia)? The finger
is again rotated so that the pulp of the
finger looks backwards. The patient is
again asked to cough. Tf the impulse is
felt on the pulp of the finger the hernia
is n direct one and if the impulse is felt
on the tip it is an oblique hernia.
Figs.38. 15 & 38. 16. - Ring occlusion test after 8. Ring occlusion test.- This test
reduction of an inguinal hernia. The deep inguinal
is performed in s tanding pos ition and
ring is being occluded with the tip of the thumb. The
patient is now asked to cough. In case of indirect
the h ernia mus t be reduced firs t. This
hernia no bulging will be seen whereas in case of is a confirmatory tes t to diffe rentiate an
direct hernia (as shown in the second figure) the indirect inguinal hernia from a direct
hernia comes out. inguinal hernia. Since an indirect
(oblique) hernia comes out through the
deep ing uinal ring and a direct he rnia medial lo the ring, pressure over the deep
inguinal ring w ill occlude the indirect hernia but not the direc t h ernia. A thumb is
pressed on the deep inguinal ring (½ inch above the mid-point between the anterior
superior iliac spine and the syrnph ysis pubis). The patient is asked to cough. A direct
he rnia wi ll show a bulge medial to the occludin g finger but an indirect hernia w ill no t
fi nd access . See Figs. 38.15 and 38.16.
Tn case of femoral he rnia if pressu re is exe rted
ove r the fe mora l can al the hernia w ill not be able to
come out. This is a confirmatory test for femoral
hernia.
9. rn case o f child a small inguinal he rnia is
often invisible due to presence of thick pad of fa t over
the inguinal region. To make visible such a hernia the
child is asked to jolt or jump from the examining
table or d eliberately ma ke it cry according to its age.
Now palpate the spermatic cord as it emerges from
the superficial inguinal ring. 1£ there is a hernia the
cord will be Celt thicker th an its fellow on the opposite
s ide due to p resence of he rnial sac. Even wh en this
test fails Cornn/l's test is performed. The child is held
from back by both hands of the clinician on its
abdomen. The abdomen is pressed and the child is
IHted up. This will ma ke the he rnia appare nt by
Flg.38 . 17 .- An encysted
increasing intra-abdominal pressure.
hydrocele of the cord comes down
PERCUSSION.- A resonant note over a hernia and becomes fixed when the testis is
means it contains intes tine (enterocele). Whereas if the pulled down.
no te is dull it contains omentum or extraperitoneal
602 A MANUAL ON CLINICAL SURGERY

fatty tissue. Percussion can differentiate acute

epidid ymi tis and acute filarial funiculitis from
strangulated hernia. The note will be resonant in
case of the latter whereas in case of former two
cases the note will be dull.
AUSCULTATION. - This does not give much
diagnos tic clue. Peristaltic sounds may be h eard in
an enterocele.
Examine the testis, epididymis and spermatic cord
as discussed in ch ap ter 40. This part of examination
is v ery important. In traction test the testis is p ulled
downwards and with this the encysted h ydrocele of Fig. 38 . 18.- Percussion on an
the cord descends slightly and becomes fixed . inguinal hernia will give indication
Exa min e the tone of the abdominal muscles to about its contents - an enterocele
select the type of operation suitable for the particu lar (resonant) or epiplocele (dull).
case. The tone can be examin ed in the fo!Jowing
ways : (a) To observe the patient in profile. Undue protrusion of the lower abdomen
denotes loss of tone. (b) In recumbent position the patient is asked to raise his s hou lders
against resistance. When oblique muscles are s trong, retraction of the abdominal wall
w ill be observed over the flanks. When the abdominal muscles are weak this test will
demonstrate the 'Malgaigne's bulgings' in the inguinal region or just above it. These are

Figs.38.19 & 38 .20.- Methods of estimating the tone of the abdominal muscles (a) by observing
the patient in profile and (b) by 'rising test' to demonstrate Malgaigne's bulgings.

oval-shaped lon gitudinal bila teral bulge produced on s training, above and parallel to the
m edia l h a lf of the inguinal ligame nt i.e. along the inguina l cana l. It indicates poor tone
of the oblique muscles . (c) A finger is introduced into the superficial inguinal ring and
the patient is asked to cough. The s trength of the two pillars and the sph incteric action
of the conjoined tendon can be assessed.

GENERAL EXAMINATION
Thorou gh examina tion mus t be performed to exclude ch ronic bronchitis, enlarged
EXAMINATION OF A CASE OF HERNIA 603

prostate, stricture urethra, chronic constipa tion e tc., which will induce chronic s train as
to cause hernia to develop.
The chest must be thoroughly examined to exclude any cause of chronic cough.
Rectal examination is obligatory to exclude chronic cons tipation and enlarged prostate.
Abdomen shou ld always be examined to exclu de presence of intestinal obstruction.

DIFFERENTIAL DIAGNOSIS

INGUINAL HERNIA
A. ANATOMICAL TYPES.- Three types of classifica tion can be made under this
heading. According to the extent of the hernia it can be ei the r (a) a bubonocele - when
the hernia does not come out of the superficial inguina l ring. (b) nn incomplete hernin
- when it comes out through the s uperficial inguinal ring but fails to reach the bottom
of the scrotum, and (c) n complete hernin - when it reaches the bottom of the scrotum.
According to its site of ex it it can be either (a) nn oblique (indirect) hernia - when
the hernia comes through the deep inguinal ring i.e lateral to the inferior epigastric a rtery
and (b) n direct hernia - w hen it comes out through the Hesselbach's triangle which
is bounded medially by the lateral border of the rectus abdominis, lateral ly by the inferior
epigastric artery and below by the inguinal ligamen t. That means the neck of the sac
lies medial to the inferior epigastric artery.
According to the contents of the hernia, a hernia may be either (a) an en terocele -
w hen it contains the intestine (enteron); (b) an epiplocele or omentocele - wh en it contains
omentum (epiploon); or (c) a cystocele when it contains the urinary bladder.
OBLIQUE. (IND/RE.CT) HERNIA.- It comprises more than 80% cases of inguinal
hernia. Almost a ll the herniae in children and women are of this type. It occurs ea rlier
than a direct hernia. It is often complete i.e. it reaches the bottom of the scrotum. The
hern ia descends obliquely downwards and inwa rds and it reduces obliquely in the
opposite direction. This type of hernia does not reduce by itself and if reduced, does
not come out at once, but requires a cough to bring it down. For reduction a little
manipulation is required. If the internal ring is occluded the hernia cannot come out
even if the patient coughs. Two forms of indirect inguinal hernia are found in practice;
(i) congenital and (ii) acquired.
Congenital hernin.- Normally the funicular process of peritoneum becomes obliterated
after the testis has reached the scrotum. The scrotal part of the process remains pa tent
and acquires the name ' tunica vaginalis' . In case of congenita l hernia the wh ole process
remains patent. With increase in the abdominal press ure abdominal contents come out
through the patent peritoneal process. Thus a congenital hernia reaches the bottom of
the scrotum very quickly. It may so h appen that the funicular process remains patent
up to the top of the testis. So the h ernia s tops at the top of the testis and is known
as a congenital funicular hernin. It must be remembered that congeni tal hernia, though so
named, is u sually seen in adults.
Acquired hernia.- As the name s uggests it does not protrude into a pre-formed sac.
Clinically it can be differentia ted from a congenita l hernia by the fact that it does not
become complete at once. Acqu ired hernia progresses gradually.
604 A MANUAL ON CLI NICAL SURGERY

Fig.38.2 1.- Con- Flg.38.22.- Con- f l g . 38 . 23 . - Flgs .38.24 & 38.25.- Two
gen i ta I vaginal geni tal funi cular Acquired hernia . types of infantile hernia.
hernia . hernia.

This h ernia is more common above the a ge of 40. It is frequently

i_ncomplete, but it may descend into the scrotum if remains untreated for years. The
herni a comes out as soon as the patien t stands and disappears immediately when h e
lies down. The swell ing is more ofte n s pherical in shape. In case of invagination test
the finger goes d irectly backwards instead of upwa rds, backwards and laterally (in case
of indirect hernia) . When the patient is asked to cough after occlud ing th e deep inguinal
ring the hernia com es out medial to the occluding finger. Direct hernia does not come
out throu gh the deep inguinal ring but a little medial to the ring. It becomes rarely
stran gu lated as the neck of the sac is w ide.
Enterocele is elas tic in cons is tency, resonant on percussion and slips back into th e
abdomen with a dis ti nct gurgle. Peris ta lsis may occasionally be seen if the coverings
a re thin. Peristaltic sound can be heard on ausculta tion. Red uction may be difficult in
the beginning but easy towards the end.
Epiplocele feels doughy an d granular. rt is dull on percussion and red uces without
gu rgle. Red uction may be easy in the beginning but is difficult towards the end .
Cystocele on ly occurs in a direct hernia or in s liding he rnia. It is s uspected when
the patient gives the history that the hernia gets enlarged just before m ictu rition and
smaller after micturition. Pressure on the h ernia induces a desire for micturition
particularly when it is dis tended.
B. CLINICAL TYPES.- Clinically h ernia may be of five types :
1. Reducible ltemia. - Normally an uncomplicated hernia is reducible. That means
its con tents can be returned into the abdominal cav ity, but the sac remains in its
position.
2. Irreducible hemhl.- In this h ernia the contents cann ot be returned to the
abdomen, but it d oes not suggest any oth er complication w h atsoever. Various causes of
irreducibility are :- (i) adhesion of its contents to each other, (ii) adhesion of its contents
with the sac, (iii) adhes ion of one part of th e sac to the other part, (iv) sliding hernia
and (v) ve ry large scrotal hernia (scrotal abdomen). Irreducible hernia is often confused
w ith s tran gu lated h ernia by the beginners. Clinically a s trangulated h ernia is also
irreducible, but it is extremely tender and tense and the overlying skin may be red. These
s igns are absent in a pure irredu cible h ernia.
3. Obstructed or i11carcerated hemia (irredu cibility+Intes tinal obstruction). - An
EXA,\,HNATION OF A CASE OF HERNIA 605

obstructed hernia means the hernia is associated with intestinal obstruction due to
occlusion of the lumen of the bowel. It must be remembered that there is no interference
w ith the blood supply to the in testine in this hernia. One must be very carefu l to make
this diagnosis, as strangula ted hernia also possesses two of its features i.e. irreducibility
and intestinal obstruction. Of course the third and most important feature of a s trangulated
h ernia is missing in this hernia i.e. interference with the blood supply of the intes tine.
So it is a dangerous venture to diagn ose obstructed hernia when s trangulation may be
the real s tate of affair and thus valu able time will be wasted un til it b ecomes too late
to save the patient's life .
4. Straugulated hernia (irreducibili ty+obstruction+arres l of blood s upply to the
contents).- A hernia is said to be strangulated w hen the contents are so cons tricted
as to be interfered w ith their blood supply. Intestinal obs truction m ay not be p resent
particularly in case of omentocele, Richter's h ernia and Littre's h ernia. Diagn osis of
stran gulation is made when a hernia is irreducible, without any impulse on coughing,
extremely tense and tender. These are followed by fea tures of acute intes tinal obstruction .
5. Inflamed h ernia.- This is a very rare condition and mimics in many respects
a s trangula ted h ernia. This hernia m ay occur w hen its content s uch as an append ix,
a salpinx or a Meckel's diverticulum becomes infla med . Diagnosis is made by the
presence of constitu tional disturbances associa ted wi th local s igns of inflammation -
overlying skin becomes red and oedema tous and the swelling becomes p ai nful, tender
and swollen. The only differentiating feature from a s trang ula ted hernia is that this
he rnia is n ot tense and is not associated with intestinal obstruction.
Ra re varieties of hernia a re :- 1. Hcrnia-en-glissade or Sliding Hernia.- Tn this type
of hernia a piece of extra.peritoneal bowel, usually the caecum on the right s ide or the
pelvic colon on the left side or the urinary bladder on either s ide slides down outside
the h ernia l sac forming a part of its
wa ll being covered by the peritoneum
on the h ernial aspect only . There
may be the usual contents in the
sac. These he rniae us u ally occur in
older men. A large globular hernia
when descends well into the scro tum
this cond ition is sus pected. Tt
reappears s lowly after reduction .
This condition may be associated
with s trangulated sm all intes tin e
w ithin its sac or a s trangula ted la rge
intes tine outs ide th e sac.
2. Ric hter's hernia.- In this
Flg.38.26. - Hemia-en- Flg. 38 .27 . - Maydl 's condition only a p ortion of the
glissade or sliding hernia. hernia. The loop in the ci rcumfe re nce of the bowel becomes
The thick line represents abdomen is always found s trangula ted. This condition often
the peritoneum, Note that at a more advanced stage complicates a femoral hernia and
the colo n forms the wall of strangulation than the
rarely an obturator h ernia. This
of the sac. loops in the sac.
condition is particularly dangerous
as operation is frequently delayed because the clinical fea tures resemble gastroenteritis.
606 A MANUAL ON C LIN ICAL SURGERY

Intes tinal obs truction may not be present until and unless half of the circumference of
the bowel is inv olved. The patient may or may not vomit, intestinal colic is present but
the bowels are opened normally. There may be even d iarrh oea. Absolute cons tipa tion
is delayed until paralytic ileus s upervenes.
3. Littre 's hern ia is a hernia which contains Meckel's diverticulum.
4. M ayd l's he rnia ( Hernia-en- W) or retrograde strangulation.- In this condition two
loops of bowels rem a in in the sac and the con necting loop remains within the abdomen
and becomes s trangulated. Th e loops of the h ernia look like a ' W' . The loop within the
abdomen becomes first strangulated and can only be s uspected when tenderness is
e licited above the ing uinal ligament along with presence of intes tinal obstruction.

FEMORAL HERNIA
A femoral hernia is a protrus ion of extraperitoneal tissue, peritoneum and sometimes
abdominal contents through the femora l canal. The femora l canal is bounded
superoanteriorly by the inguinal ligament, inferoposteriorly by the pubic ramus and
pectineus muscle, medially by the lacuna r ligament (Gimberna t's ligament) and laterally
by the fem oral vein. The hernia actually comes out superficially through the saphenous
opening situated 1½ inches below and lateral to the pubic tubercle. When the hernia
is within the femoral canal it remains narrow, but on ce it escapes through the saphenous
opening into the loose areolar tissues, it expands cons iderably. So a femoral hernia
assumes the shape of a retort. Its bulbous extremity exp ands up wa rd s even above the
inguinal ligament.
Femoral hernia is very rare before 20 years of age. The incid en ce gradually rises
till the highest incidence
is over 50 years. Femoral
hernia is commoner in
women (2 : 1). But the
s tudents mus t remember
that even in women the
commonest hernia in the
groin is the inguinal
hernia. The right side is
affected twice as common
as the left side and in 20
per cent of cases the
condition is bilateral. The
symptoms from femoral
h ernia a re less flg.38.28.- Anatomic representation of the position of the femoral
ring.
pronounced than those of
inguinal hernia. One thing mus t be borne in mind that the femoral canal being a rigid
opening this hernia becomes strangulated very often.
The femoral hernia is differentiated from an inguinal hernia by the following points
: (a) The fem oral h ernia lies latera l to the pubic tubercle and below the inguinal ligament
but in late stage it may extend up above the inguina l ligament, w hereas an inguina l
hernia lies medial to the pubic tubercle and above the inguinal ligament. (b) In case
EXAMINATION OF A CASE OF HERNIA 607

of femoral hernia impulse on coughing can be seen and felt on the saphenous opening
which is about 4 cm below and lateral to the pubic tubercle. (c) In case of femoral hernia
the inguinal canal will be empty as determined by the ' invagination tes t'. (d) By
occluding the deep inguinal
ring an indirect hernia can be
s topped coming out even if the
pa tient coughs, but the direct
Inguinal Ligament
hernia will bulge medial to the
Inf••'°' Ep,gasu,c deep inguinal ring. Similarly a
Ves sei, femoral hernia can be
prevented from coming out by
pressure applied over the
Hemoa Comes out
External Hiac Vessels
femoral canal or the saphenous
Otnurator Nerve
ind Artery opening.
PRE-VASCULAR FEMORAL
HERNIA- This is a special
Fig.38.29.- Ano ther anatomical representatio n of re lative variety of femoral hernia,
positio ns of deep inguinal ring and femoral ring which are shown which descends not through
from inside the abdomen thro ugh which inguinal hernia and the femoral canal, but bulges
femoral hernia come out respectively. down posterior to the inguinal
ligament and in front of the
femoral artery and vein. Obviously it has a
wide neck and a flattened wide sac. This hernia
is not difficult to diagnose and can be reduced
easily. Such hernia rarely gets strangulated and
is very difficult to repair.
A femoral hernia should be differentiated
from :
1. Sapbena varix. - It is a saccular
enlargement of the termination of the long
saphenous vein. This swelling usually
disappears completely when the patient lies
Psoos down. The so called impulse on coughing is
ol.seess present in this condition as well, but it is
actua lly a fluid thrill and not an expans ile
impulse to the examining fingers. Yaricosity of
the long saphenous vein is usually associated
with.
Fig.38.30. - Psoas abscess usually points in
Percussion on varicosities of the long
the groin latera l to the fe moral vessels. The saphenous vein will transmit an impulse
track of the psoas abscess from the caries spine upwards to the saphena varix felt by the fingers
is shown in the figure. It must be remembered of the other hand - Schwartz's tes t. Sometimes
that femoral hernia lies on the medial side of a v enous hum can be heard when the
the femoral vessels. s te thoscope is applied over the saphena varix.
2. Enlarged lymph nodes.- A search for a
possible focus of infection should be made in the drainage area which extends from the
608 A MANUAL ON CLINICAL SURGERY

umbilicus down to the toes including the terminal portions of the anal canal, urethra and
vagina (i.e. portions Inguinal Ligament
d eveloped from the
ectoderm). Causes of
enlar gement of lymph nodes Femor al Vein
are discussed in chapter 8.
The gland of Cloquet lying Gimbemars Ligament
w ithin the femoral canal
may be enlarged and Femoral Canal
simulates exactly an
irreducible femoral hernia.
Coopefs Ligament
If any focus cannot be Pectlneus Muscle
found out or any cause of Superior Ramus or Pubis

enlargement of lymph nodes

cannot be detected, the Fig.38.31.- Boundaries of the femoral canal.
nature of the lump remains
a matter of opinion which is best settled urgently in the operation theatre.
>·• a J. c< (Fig.38.30).- This is usually a cold abscess tracking d own from
Pott's disease. It is a reducible swelling and gives rise to impulse on coughing. Ct is
a painless swelling an d if the
p ulsation of the femoral artery can
be pa lpa ted it w ill be apprecia ted
tha t the swelling is lateral to the
artery. Sometimes the re is a n iliac
pa rt of the abscess which is
dete rm ined by cross-fluctuation.
Examina tions of the back and
correspond ing iliac fossa including
X-rays clarify the d iagnosis.
4 An enlan•ed f)'-Oll!I bur a.-
This bursa lies in front of the hip
joint and w1der the psoas major
Flgs.38.32 & 38.33.- Femoral hernia in male, a rare
muscle. It often communicates with
occurrence. In the first figure, the tip of the finger lies over the
pubic tubercle. In the second figure 'invagination test' is being the hip joint. In osteoarthritis of
demo nstrated. The inguinal canal is empty in a femoral hernia. the hip joint this bursa becomes
enlarged and produces a tense and
cys tic swelling be low the inguinal ligam ent. This swelling diminishes in size when the hip
joint is flexed. Presence of os teoa rthritis in the hip join t, a cystic swelling, absence of
imp ulse on coughing and tha t the swelling diminishes in s ize d uring flexion of the hip
joint are the diagnostic points in favou r of this condition .
, \ t'unoral 1rneun~m. Expansile pulsation is the pathognomonic feature of this
condition.
h L 11oma - The diagnostic points in favour of this condition are discussed in chapter 3.
I Hlr c-. e :,( emo 1I en 1·11 qr.- This is an extremely rare condition in which
the neck of the sac becomes p lugged with omentum or by ad hes ions. The h ydrocele of
the sac is thus produced b y the secretion of the peritoneum.
EXAMINATION OF A CASE OF HERNIA 609

UMBILICAL H ERNIA
Any hernia w hich appears to be closely rela ted to the umbilicus can be called as
"Umb ilical h ernia". Four definite varieties are seen :
fHir n lo Abdominal con tents are protruded into the umbilicnl cord being
covered by a transparent membrane - a diaphanous membrane.
. Conp:111t.1 um luhc.1I hunia.- This hernia com es out through the centre of a
congenital weak umbilical sca r. It is common in Negroes. It generally appears in the
first few m on ths a fter birth. Common symptom is the swell ing ra ther tha n anything else.
The neck of the hernia is gen erally wide and hardly gives rise to intestinal obs truction
or strangulation . The mai n d iagnostic features are - (i) Bulge through the cen tre of the
umbilical sca r everting the w hole umbilicus; (ii) Age of th e patient; (ii i} The swell ing
is easily red ucible (spontaneously reduced w hen the child lies d cown) and the re is
definite impulse on crying; (iv) The size of the he rnia varies - it may be a s mall defect
ad m itting the tip of the little finger alone to quite a large opening admitting two or
three fingers; (v) The content is usually small intes tine, so resonant to percussion; (vi)
About 90% of these herniac disappear spontaneously during the firs t 5 yea rs of life as
the umbilica I scar thickens and contracts .
., .\cq1 i td umbilicnl hernia. - This hernia occurs in adu lt life and protrudes
through the umbilica l scar. It is very r are in comparison to the para-umbi lical hernia
which is descri bed below. Almos t invariably it is due to raised intra-abdominal pressure
w hich h as forced the hernia through the umbilical scar. One mus t try to find out the
cause of raised intra-a bdomin al pressure in these cases. Common causes are - pregnancy,
ascites, bowel dis ten sion , ovarian cyst and fibroid.
l. Para- u111h1hcal hernia. - It is the commonest acquired umbilica l hernia. It occurs
through n defect adjacent to the umbilicus. The us ual site is just above the umb ilicus
between the two recti, in fac t lower half of the fundus of the sac is covered by the
umbilicus. The diagnostic features are as follows : (i) Para-umbilical h ernia develops in
the middle and old age; (ii) Obese women are more commonly affected; (iii) Usual
symptoms are pain and swelling. If the swelling is very small, it may not be noticed
by the patient and the pain and discom fort become th e main symptoms; (iv) The surface
is sm ooth and the edge is distinct except when the patient is very fat; (v) It contains
omentum or bowel. The lump is firm when it con tains omentum. The lump is soft and
resonant to percussion when the content is bowel; (vi) Many par aumbilical herniae are
irreducible when the contents become adheren t to the sac or the neck of the sac becomes
na rrow. If the hernia can be reduced, the firm fibro us ed ge of the defect in the l inea
alba can be felt; (vii) As the defect in the linea alba is firm and does not e nlarge
proportionately these h erniae do give rise to intermittent abdomin al pain, though
strangu la tion is not common.

EPIGASTRIC HERNIA
An epigastric hernia is a protrusion of extra-peritoneal fa t and :sometimes a sma ll
p e ritoneal sac through a defect in the Linea alba. This defect is usually placed somewhere
between the xiphis ternum and the umbilicu s. The main symptom is E!pigastric pain and
swelling. Pain is usually located over hernia. It often begin s a fte r eating probably due
to epigastric distension. If the patient could n ot see the lump, a self-diagnosis of peptic
39
610 A MANUAL ON CLINICAL SURGERY

ulcer is often made. So w hen ever a patient w iU compla in of epigastric discomfort or pain
pa lpa te the abdominal wall first to de tect a sma ll lump of epigastric hernia. It mus t
be remembered tha t usua lly these herniae do not have impulse on coughing and cannot
be reduced . Lipoma very much resembles this condition . That the swelling cannot be
moved over the unde rl y ing s tructures favours the diagnosis of epigastric hernia.
INCISIONAL HERNIA is the hernial protrus ion th rough the sca r, us ually due to
prev ious s urgica l opera tion or accidental tra uma. Infection of the wound and injury to
the motor nerve predispose hern ia fo rmation.
DIVARICATION OF THE RECTI.- Jn this condi tion the linea alba s tretches and
allows the two recti muscles to part from each other. These two muscles are inserted
to th e pubis very close to the midline. By repeated contractions of the fla t muscles of
the abdomen the two recti show tendency to di verge pa rticula rly when the linea alba
is weak. This condition is common in elde rly multipara.
INTERSTITIAL HERNIA. - This is a lso called an lnterpnrietal hernia. In this condition
the he rnia l sac passes between the layers of the ante rior abdominal wall. This sac may
be a continuation of an inguinal or femoral he rnial sac.
SPIGELIAN HERNIA.- Th is he rnia occurs through the linea semilunaris a t the level
of the arc ua te line i.e. a few centi me tres above the inguinal ligament. Usual victims are
above 50 years of age.
LUMBAR HERNIA.- This hernia com es out th rough the Petit's triangle being
bounde d below b y the crest of the ilium, laterally by the external oblique and medially
by the latissimus dorsi. There is another superior lumbar triangle being bounded by th e
12th rib above, by the sacrospinalis medially and the posterior border of the internal
oblique la tera lly. Through this triangle also the contents m ay come ou t of the abdomen.
But the incidence is ra re r tha n infe rior lumba r he rnia through Pe tit's tria ngle. Tncisional
lum bar hernia may follow an operation on kidney, the incisiona l wound being infected.
OBTURATOR HERNIA.- This hernia comes out th rough the obtura tor foramen . As
th e hernia is covered by the pectineus muscle, it is ofte n overlooked . This he rnia causes
more pain than any oth er type of hernia. Pain often rad ia tes along the obturator nerve
and may even be referred lo the kn ee v ia its geniculate branch. The leg is usually kept
in the semiflexed pos ition and movemen t of the limb gives rise to pa in. Tf the limb is
flexed , abducted and ro ta ted ou twa rds the hernia becomes prominent. Patients are mos tly
over 60 years of age and wome n a re more frequen tly affected than men. Incidence of
Richte r's hernia in this condition is only second to femora l hernia.