HERNIA. 



743 



have seen and dissected a case of this descrip- 

 tion in which the tumour during life reached to 

 within two inches of the knee, and obliged the 

 unfortunate subject of it (who was a lamp- 

 lighter) to wear a petticoat instead of breeches. 

 Similar instances are not very unfreqnent, and 

 it is obvious that an attempt at reduction here 

 would be injudicious even if it was practicable. 

 It is the nature of all hollow structures in the 

 body, whether cavities or vessels, to accommo- 

 date their size and capacity to the quantity of 

 their contents, and the cavity of the abdomen 

 will, under such circumstances, become so con- 

 tracted as to be either incapable of immediately 

 receiving the protruded viscera again, or else 

 the sudden distension will excite peritoneal 

 inflammation an evil greater than the existence 

 of the hernia. These latter, however, cannot 

 be regarded as permanently irreducible, for 

 Arnaud, Le Dran, and Hey have succeeded 

 in gradually restoring them by means of a 

 bandage shaped like a bag, which being laced 

 in front admitted of being tightened still as the 

 tumour diminished. 



The last and most fearful condition of a rup- 

 ture is its state of strangulation, in which the 

 protruded viscus, no longer capable of being 

 returned to its former situation within the ab- 

 domen, no longer fit for the performance of its 

 functions, is banded and bound down at its 

 neck in such wise as to interrupt and impair 

 the circulation through it. In order properly 

 to understand this part of the subject, it will be 

 necessary to consider it under three heads : 

 1. the causes that seem to produce the stran- 

 gulation ; 2. its effect on the structures within 

 the hernial sac ; 3. its effect on the viscera 

 within the cavity of the abdomen. 



1. Of the three natural apertures at which 

 abdominal herniae commonly occur, one, the 

 umbilicus, is unquestionably seated within 

 tendon, and so circumstanced that any con- 

 traction of any muscle connected with it, whe- 

 ther spasmodic or permanent, must rather ex- 

 pand the opening than contract it. Another, 

 the crural ring or canal, is composed of tendon 

 and of bone, and so constructed that although 

 certain positions of the trunk or inferior extre- 

 mity might possibly diminish its size, no mus- 

 cular action can exert any influence over it. 

 The third, the inguinal canal, is of greater length 

 and more complicated in its construction, and 

 it is a question whether the same pathological 

 condition can be predicated of it, or whether 

 strangulation does not here occasionally occur 

 in consequence of muscular action alone.* Sir 

 A. Cooper seems to acknowledge the possibility 

 of a spasmodic stricture at the internal ring, the 

 strangulation then being effected by a com- 

 pression exercised by the inferior edge of the 

 internal oblique and transversalis muscles.f 

 Guthrie speaks of herniae being frequently 

 strangulated by passing between the fibres of 

 the internal oblique, which are separated at the 

 inferior and external border of the muscle above 



* See the anatomy of inguinal and femoral hernia 

 in a future part of this article. 

 t Cooler on Hernia, p. 21. 



the origin of the cremaster.* Scarpa says that 

 " towards the side, at about eight lines distance 

 from the apex of the ring, the lower muscular 

 fibres of the internal oblique muscle separate 

 from each other to allow the spermatic cord to 

 pass between them :"f and again, " the small 

 sac or rudiment of the hernia, not unlike a 

 thimble, when it makes its first appearance 

 under the fleshy margin of the transverse, rests 

 immediately on the anterior surface of the 

 spermatic cord ; it then extends and passes in 

 the middle of the separation formed by the 

 divarication of the inferior fleshy fibres of the 

 internal oblique and of the principal origin of 

 the cremaster muscle."]; It must, however, be 

 conceded that Scarpa did not attribute the 

 strangulation of any form of inguinal hernia to 

 a contraction of these muscular fibres. Now, 

 although it is almost presumptuous to differ 

 from authorities of so high a class, yet I cannot 

 agree either with the opinion that herniae are 

 liable to a spasmodic constriction, or with the 

 descriptive anatomy on which such an opinion 

 might be founded. 



In about one subject out of every three or 

 four there certainly is a slight divarication or 

 separation of fibres of the external oblique 

 muscle, or rather there is a cellular connexion 

 between the origin of the cremaster muscle and 

 the inferior fibres of the oblique, which is easily 

 separable by the knife ; but the question is, 

 does the spermatic cord in the natural condition, 

 or the hernia in its course to the external ring, 

 pass through or between these fibres ? I believe 

 they do not. I have dissected numerous cases 

 of hernia without observing such a disposition 

 of parts, and I think that if either the spermatic 

 cord or the hernia took such a course, the pro- 

 trusion must then come to lie in front of the 

 cremaster muscle a position that has not been 

 hitherto observed. When a hernia is found at 

 the groin, the tendon of the external oblique is 

 somewhat stretched and arched forwards above 

 Poupart's ligament in front of the inguinal 

 canal : the fascia transversalis may be stretched 

 also, and the epigastric artery pulled out of its 

 place and made to approach the linea alba; 

 but the muscles arising from Poupart's liga- 

 ment, the internal oblique and transversalis, re- 

 main unchanged, and if ever strangulation is 

 effected through their operation it is in the 

 manner suggested by Sir A. Cooper. But it 

 is more simple and perhaps more scientific to 

 place muscular contraction out of the question 

 altogether. The phenomena of strangulation 

 exhibit nothing like the irregularities of spasm: 

 there is no sudden exacerbation, no succeeding 

 relaxation no alternation of suffering and re- 

 lief, no assuagement of symptom from medi- 

 cines decidedly antispasmodic; the disease once 

 established goes on with an uninterrupted and 

 certain progression that will not admit of expla- 

 nation by a cause so irregular as spasm. 



But it is unnecessary to resort to an expla- 

 nation which might prove so practically dan- 



* Guthrie. 



t Scarpa, op. cit. p. 27. 



J Ibid. p. 50. 



