672 THE BRITISH JOURNAL OF SURGERY

A CASE OF LUMBAR HERNIA.

BY HAROLD EDWARDS, LOKDON.

ALTIIO~JGII tlic possibility of herniation occurring in the lumbar region is well

kllown t o the stiident of anatomy, the condition is in effect a very rare one
for thc surgeon t o meet. The following case occurred recently in the Surgical
Clinic of King’s College Hospital, and I am indebted to Mr. Arthur Edmunds,
uliclcr wliosc: (:arc the paticiit was, for pcrniissioii to publish this rccorct.
HIwoin7:--l<. G., age 19 years, first attended the Out-patient Depart-
inelit of‘tlic PIospitnl in December, 1925. Hc then stated that twclvc months
ago he felt a pain in the right loin after a hard day’s
work. His occupation is that of a plater’s assistant,
which consists of grinding and polishing nickel plates,
and involves lifting and carrying hcavy cast-iron boxes,
which require his full strength t o move. He noticed a
lump iri the right loin a t the t.imc hc had the pain. It
was not big, and disappeared after a few days. It hurt
him on coughing.
Nothing further was noticed until December, 1925,
when the pain recurred towards the end of a day’s
work. On that particular day he had not donc
any heavy lifting. It was on the day following the
onset of the pain that he attended hospital, when a
swelling was seen in the right lumbar region.
ON knmsIoh..-Thc patient was admitted into
~~~~1 s L1I ~ O sit.0
~ I l t l ( i r(+i-
a surgical
any ward onA Jan.
serious illness. 20. He
well-defiiicd was a 3 well-built,
swelling, in. x 1 in.,
Fro. 47R.-Vie clingrain
muscular boy of medium height, and had nevcr suffered
tivo size of ilio Iieriiia
witll t,lo ic,,lt OI’O~t, presented just above the iliac crest, 24 in. from the
posterior superior iliac spine (Fig. 478). The swelling
was soft, not attached t o the skin, and reducible on firm pressure. An
inipulse was felt on coughing, but i t was not espansile. A diagnosis of fatty
heriiia WIS ni:itie, and operation performed.
OI.JztI(aTroN.--TTiider thc anzsthetic, and with thc patient recumbent,
the lump 1i:itl 1)ractically disappeared. A crescentic flap of skin with the base
forwards was dissected up over the swelling, and the latissimus dorsi and
external oblique niuscles were exposed a t their attachment t o the iliac crest.
Tlic two a.tt:r.c*ttrricntsapproxiniatcd very closely, and thcrc was no ‘ Pctit’s
triauglc’.
The latissimus dorsi was partially cut through near its iliac origin and
reflcctcd. The coiiditioii represented in Fig. 479 was iiow seen. The post.erior
border of the iriteriial oblique muscle and the free border of thc erector spinre
muscle met a.t an acute angle above the iliac crest. Between the two, and on
a deeper plane, ran the horizontal fibres of the transversalis aponeurosis,
which latter structure was rendered prominent by the subjacent swelling.
Thc swelling thus occupied the angle formed by the internal oblique and
erect.or sl)intc: rnusrles, which representcd the lower part of thc space described
 RARE OR OBSCURE CASES 673
by Grynfelt and Lesshalft. The twelfth nerve crossed the space over the
most prominent part of the swelling, emerging from underneath the erector
spin% muscle to pass deep to the internal oblique muscle. The aponeurosis
covering the swelling was thick and granular, and was a t first thought to
be granulation tissue. Microscopic section of a portion removed showed,
however, that it consisted of dense fibrous tissue, fatty tissue, and some
striped muscle.
After retracting the twelfth nerve the aponeurosis was incised in the
direction of its fibres, and on dissecting through the transversalis fascia a
lobulated fatty tumour presented. This was drawn into the wound and
with it a knuckle of large intestine to which the former was firmly adherent
(Pig. 4SO). The large intestine withdrawn was a portion of the ascending colon.

FIG. 479.-The skin-flap has been raised, and the latissiinns dorsi cnt through near its
origin from the iliac crest, and reflected away from the posterior free edge of the external
oblique muscle. It will be seen that there was no ‘ Petit’s triangle ’. The reflection of the
latissimus dorsi exposes the border of the erector spinio and internal oblique muscles as they
converge to and form tho apes of the upper lumbar triangle. The floor of the triangle,
which is crossed by thO twelft,h nerve. is formed by the transversalis fascia, which in this
region is pushed up into proniinenco by the subjacent hernia.

The hernia owned no sac-in fact, peritoneum was not csposcd a t any stage
of the operation. The fatty tuinour was dissected off the gut and removed,
and the gut returned to the abdomen. The incision in the aponeurosis was
sutured, and, after cxsecting a portion of the twclfth nerve t o avoid the
possibility of its being involved in scar tissue and causing trouble in the future,
the latissimus dorsi muscle was repaired and the skin incision closed.
‘ Grynfelt’s space ’, through which the hernia occurred, was first described
by Grynfelt in 1866. He called it the ‘upper lumbar triangle’ to distinguish
it from the ‘lower lumbar triangle’ of Petit. The triangle is bounded above
by the last rib and the lowest digitation of the serratus posticus inferior, in
674 THE BRITISH JOURNAL OF SURGERY
front by the internal oblique muscle, and behind by the erector spino. It
varies in shape, and may be triangular, deltoid, polyhedroid, or rhomboid.
This variation in shape depends upon the size of the.last rib, and the extent
of the attachment t o the latter of the serratus posticus inferior.
Watson collected 115 cases of lumbar hernia from the literature, including
all types. Of these, 30 were through Grynfelt’s triangle and 30 through the
triangle of Petit ; so that from the standpoint of the occurrence of hernia the
little-known ‘upper lumbar triangle’ is a t . least as important as the more

FIU.480.-The transversalis aponeuroais and fascia have been incised and the hernia
exposed. It consists of a fatty maas attached to the posterior wall of the ascending colon,
a portion of which hgs boen drawn up into the wound.

widely recognized ‘lower lumbar triangle’ o f .Petit. Furthermore, according

to Goodman and Spese, Grynfelt’s triangle is more constant in occurrence
than Petit’s triangle (93 per cent as opposed to 639 per cent), and has thus a
definite claim to a wider recognition by both siirgeons and anatomists.
The accompanying illustrations were reproduced by Mr. Edmunds from
sketches made a t the time of the operation.

BIBLIOGRAPHY.
GOODMAN, E. H., and SPESE,J., ‘‘ Lumbar Hernia ”, Ann. of Surg., 1916, Ixiii, 548.
GRYNFELT,J., ‘‘ Quelques Mots sur la Hernie lornbaire,” MonfpeNier Mkd., 1860, xvi,
329, 504.
PETIT,J. L., Traitt des Maladies chirurgicales, Didot, Paris, 1774, ii, 256.
TURNER,W. Y.,‘‘ Lumbar Hernia ”, Brif. Med. Jour., 1017.
WASTON,L. F., Ifernin, Kimpton, London, 1924. 437.