Perhaps the next point of practical import ance to consider is, whether, with all this ana tomical and pathological information, it might nevertheless be possible to mistake this disease and confound it with any other affection. The 11.2rnia just described may exist in two different conditions ; one, in which it is still lodged within the inguinal canal, and appears in the form of a tumour in the upper part of the groin, termed bubJnoeele; the other, in which it has escaped through the external ring, and having dropped down constitutes scrotal hernia.
When the rupture has descended no farther than the groin, there are but two affections that can bear any resemblance to it: these are, the testis itself whilst in the act of descending, if this process has been delayed beyond the usual period of life, and an enlarged inguinal gland. Ho%Never possible in eases of erural hernia (as shall be noticed hereafter), a mistake of the latter description is not likely to occur in the disease under consideration, but there is an ob servation of Mr. Colles on this subject de serving of attention. " I do not suppose," says this distinguished professor, " that any surgeon of competent anatomical knowledge could mistake it for inflammation of those lymphatic glands which 1.e in the fold of the groin, but an enlargement, whether from a venereal or any other cause, of two lymphatic glands which lie on the side of the abdomen, as high up but rather more internally than the in ternal abdominal ring; an enlargement of these glands will produce appearances resembling those of inguinal hernia." It seems almost surprising how the descent of the testicle could possibly be mistaken for a hernia when the mere examination of the scrotum would throw such an explanatory light upon the subject, but a consideration of the following circumstances will be useful in solving the difficulty. 1st, The detention of the tes ticle within the abdomen until an unusually late period is by no means so infrequent an oc currence as is generally supposed even by sur geons in considerable practice : I have heard a military medical officer observe on the great number of young men that had passed before him for inspection after enlistment, in whom one and sometimes both the testes had not de scended. 2d, The symptoms of both affections bear a general though not necessarily a close resemblance ; for the situation of the tumour is exactly the same, and if the testicle is com pressed and inflamed, the pain and tenderness and the inflammatory fever are to a certain ex tent li%e the symptoms of strangulation. But
I have not met the same costiveness, at least the same obstinate resistance of the bowels to the operation of aperient medicines, nor the same vomiting, nor the same exquisite tender ness spreading over the abdomen, and the pulse is not that small, thready, hard, and rapid vi bration that is produced by peritoneal inflam mation. In one ease I perceived that pressure on the tumour occasioned that sickening pain and sensation of faintness which a slight injury of the testicle so often produces; and I imagine that in this ease a light and very gentle per cussion might prove a useful auxiliary dia gnostic. Bin, 3rd, it does not always happen that the surgeon takes sufficient pains to inves tigate the disease before him. " Ile is apt," saps Mr. Colles,* " at once to set down the ease as incarcerated hernia, a complaint with which lie is familiar, and does not suspect the exist ence of a disease which is to him perhaps ex tremely rare. Boys sometimes indulge in the trick of forcing up the testicles into the ab domen, which may be followed by unhappy consequences, for the gland may not descend again, or if it does, perhaps a portion of in testine slips down along with and behind it, which may then become strangulated, while its presence is unsuspected and the symptoms attributed to compression of the testis." A boy, about seven years of age, had forced the left testicle into the abdomen : ten years afterwards, the inguinal ring having probably become un usually contracted, the testicle passed under the femoral arch with all the symptoms of stran gulated hernia, on account of which he was obliged to undergo the operation.-1 When the hernia has become scrotal, it then comes more to resemble diseases of the testis and of the cord, but in general these are very easily distinguished, and there are only three that could lead a practitioner into error, and then only through unpardonable carelessness; the hydrocele of the tunica vaginalis testis, the hydrocele of the spermatic cord, and the varicoeele or a varicose condition of the veins of the cord.