File:The practice of surgery (1910) (14592341017).jpg

Identifier: practiceofsurger00mumf (find matches)
Title: The practice of surgery
Year: 1910 (1910s)
Authors: Mumford, James Gregory, 1863-1914
Subjects: Surgery
Publisher: Philadelphia and London, W. B. Saunders company
Contributing Library: Columbia University Libraries
Digitizing Sponsor: Open Knowledge Commons

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rries before it none of these structures except the peritoneum.The nerve-supply of these parts is interesting, and it is wise to sparenerve-branches in operating upon hernia. The terminal branches of 202 THE ABDOMEN the ilio-inguinal nerve emerge at the external abdominal ring, and thehypogastric branch of the iliohypogastric perforates the aponeurosisof the external obliciue above and to the outer side of the external ring. There are three arteries—two of them important: the spermaticartery, which supplies the testicle; the artery of the vas deferens,lying in the sheath of the vas; and the cremasteric branch fromthe epigastric. The veins forming the pampiniform plexus make upthe bulk of the cord. If you understand the anatomy of this region,the various operations appear simple enough. The diagnosis of inguinal hernia is usually easy, though occa-sionally it may offer diffictdtics. I have said that the sw^elling maydisappear when the patient lies down. This fact of the disappearance
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Fig. 107.—Aponeurosis opened to internal ring, showing lower laorder of internaloblique muscle; transversalis fascia in deep wall of canal (de Garmo). of the swelling confirms the diagnosis of hernia. For further confirma-tion the surgeon may introduce his finger into the ring to ascertainthe presence of impulse on cough. It is not always possible to dis-tinguish direct from indirect hernia, but the practitioner should re-member that direct hernia rareh becomes large enough to descendinto the scrotum; while, on the contrary, indirect hernia may descendand cause an enormous scrotal swelling. We differentiate hernia frominguinal adenitis, which presents a hard, unvarying swelling; frominguinal sarcoma, which is hard and unvarying also; from psoas abscess,which fluctuates and may be confused with inguinal hernia; fromvarious hard and soft tumors of the testicle and cord, which tumorsare constant; and from hydrocele, which most closely resembles hernia. INGUINAL HERNIA 203 Hydrocele is

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