INTERNAL OR DIRECT HERNIA. 291 



straightness of its course, should be kept in mind during attempts to 

 reduce this kind of hernia. 



Diagnosis. This rupture will be distinguished from external How known 

 hernia by its straight course through the abdominal wall, and by the j exter 

 neck being placed close to the pubis, but when an inguinal hernia impossible 

 has attained a large size, it is impossible to tell by an external if jt is large - 

 examination whether it began originally in the triangular space, or 

 at the internal abdominal ring ; for as an external hernia increases, 

 its weight drags the internal ring inwards into a line with the 

 external, and in this way the swelling acquires the appearance of a 

 direct rupture. 



S<-at "/ ^tricture. The stricture in this form of hernia occurs most stricture: 

 frequently outside the neck of the tumour, at the opening that has 

 been formed in the conjoined tendon, though it may be inside from 

 thickening of the peritoneum ; and it may occasionally be found at situation ; 

 the external abdominal ring. 



In dividing the stricture of a large rupture which appears to be in large 

 direct, the cut should be made directly upwards in the middle of the liemia - 

 front of the tumour, so as to avoid the deep epigastric vessels, the 

 position of which cannot be ascertained. 



Variety of internal hernia. Another kind of internal hernia Rarer kind 

 (superior) occurs through that part of the area of the triangular hernia 

 space which is external to the conjoined tendon. The intestine is oblique in 

 protrudes through the wall of the abdomen close to the deep epigastric ^hS 

 artery, and descends along nearly the whole of the inguinal canal cord, 

 to reach the external abdominal ring ; so that the term " direct " 

 would not apply strictly to this form of internal hernia. 



Coverings. As the gut traverses nearly the whole of the inguinal Coverings 

 canal, it has the same coverings as an external hernia. 



Division of the stricture. From an inability to decide always in hernia - 

 the living body whether a small hernia is internal or external, the 

 rule observed in dividing the stricture of the neck of the sac is, to 

 cut down upon the mid-part of the tumour ; and if it is necessary 

 to open the peritoneum, to cut directly upwards, as in the other 

 kinds of inguinal hernia. 



UMBILICAL HERNIA, or exoinphalos, is a protrusion of the intestine Umbilical 



through or by the side of the umbilicus. It is very variable in size, 



. . , , * * i . i 11 course ; 



and its course is straight through the abdominal wall. 



Coverings. The coverings of the intestine are the skin and super- coverings 

 ticial fascia, a prolongation from the tendinous margin of the aperture 

 in the linea alba, together with coverings of the transversalis fascia, 

 the subperitoneal fat, and the peritoneum. Over the end of the become 

 tumour the superficial fascia blends with the other contiguous struc- 

 tures, and its fat disappears. 



If the hernia is suddenly produced, it may want the investment changes in ; 

 otherwise derived from the edge of the umbilicus. 



Seat of stricture. The stricture on the intestine is generally at the stricture, 

 margin of the tendinous opening in the abdominal wall ; and it may 

 be either outside, or in the neck of the sac, as in the other kinds of 



U 2 



