HERNIA. 



7. r >5 



He was admitted into the Meath Hospital 

 under the care of the late Mr. Hewson, and 

 though some years have now elapsed I can 

 well recollect the variety of opinions pronounced 

 upon it. It could be partially pushed up, but 

 re-appeared instantly on the pressure being re- 

 moved : it was slightly influenced by coughing, 

 and it was extremely tender to the touch. As 

 the patient was not confined in the bowels, and 

 in fact there was no urgency of symptom, no 

 active treatment was adopted, and the tumour 

 gradually disappeared. It had probably been 

 an effusion of fluid into the sheath of the cord. 

 The manner in which these diseases are said to 

 be capable of discrimination is as follows. Let 

 the tumour be pushed up if possible, and the 

 finger of the operator still be pressed against 

 the ring: if it is a hernia, such pressure will be 

 sufficient to prevent a re-descent ; but if it is 

 only a fluid, it will insinuate itself by the side 

 of the finger and the tumour shortly re-appear. 

 Scarpa* denies the sufficiency of this test in 

 cases of omental hernia of small size, when 

 situated so high up as to occupy and dilate the 

 inguinal ring, and asserts that he had repeatedly 

 observed omental inguinal hernia of a cylin- 

 drical form, which, when scarcely returned, re- 

 appeared again as before without the patient 

 having changed his posture or made the slight- 

 est exertion ; and in like manner hydroceles of 

 the spermatic cord, which, when pushed beyond 

 the ring, remained there as long as the patient 

 kept himself in the supine posture without 

 making an exertion. He seems to rely more 

 on the difference of consistence and regularity 

 of surface in the two tumours, and on the cir- 

 cumstance of the hydrocele being always broader 

 inferiorly, contrary to what is observed in 

 omental hernia. 



A varicose enlargement of the spermatic vein 

 is not easily confounded with hernia, unless it 

 has increased to such a size as nearly to occupy 

 that side of the scrotum : it is longer in pro- 

 portion to the diameter of the tumour than 

 hernia usually is, and its surface is hard, knotty, 

 and uneven.f These circumstances, however, 

 are not sufficient to remove all obscurity, and a 

 farther investigation must be made by placing 

 the patient in the horizontal position and endea- 

 vouring to empty the vessel ; then let him 

 stand up whilst firm and accurate pressure is 

 maintained upon the ring. If it is a hernia, 

 the tumour will not re-appear; but if varicocele, 

 it will return as speedily or perhaps more so 

 than if no pressure had been made. Mr. 

 CollesJ mentions that a varicose state of the 

 cord may be combined with hernia, throwing 

 great obscurity on the nature of the disease, 

 and for obvious reasons increasing the diffi- 

 culty of its management. 



Inguinal hernia by direct descent. I now 



* Op. citat. p. 98. 



t These symptoms are not certainly characte- 

 ristic of varicocele. There is a preparation in the 

 Museum of Park Street taken from a man who 

 exhibited them all during life. His disease was an 

 enlarged, knotted, and contorted condition of the 

 vessels of the cord. 



\ Op. citat. 



proceed to offer a few remarks on the other 

 form of inguinal hernia, that by direct descent,* 

 which occurs when, instead of passing through 

 the canal, the protruded viscus is pushed out 

 immediately behind the situation of the ex- 

 ternal ring, through which it passes directly. 

 The inferior part of the inguinal canal is the 

 weakest of all the parietes of the abdomen. 

 Externally, independent of the external oblique 

 muscle, it is protected as far as the external 

 third or half of Poupart's ligament by the 

 fleshy fibres of the internal oblique and trans- 

 versalis muscles, and by the fascia transversalis, 

 which is dense and strong in this situation, but 

 becomes gradually weaker internally, and is 

 nearly lost before it reaches the mesial line. 

 More internally it is supported by the conjoined 

 tendon of these muscles, but as it arches over 

 the spermatic cord that portion of the peri- 

 toneal cavity which corresponds with the inferior 

 and posterior part of the inguinal canal must 

 depend on the fascia transversalis alone, now 

 becoming- weaker and less capable of resist- 

 ance. More internally still, and immediately 

 behind the external ring, this region is best 

 supported, and there are many natural obstacles 

 to the production of hernia in this situation. 

 Besides the fasciae already mentioned as tending 

 to prevent the separation of one pillar of the 

 ring from the other, and thereby offer an ob- 

 stacle to the passage of any viscus through it, 

 there is anotherf of a triangular shape arising 

 by a pretty broad base from the crest of the 

 pubis, and inserted into the lineaalba for about 

 an inch or an inch and a quarter. It lies 

 behind the tendon of the external oblique, and 

 before that of the internal oblique and trans- 

 versalis, which latter it strengthens materially, 

 and its external edge contributes to close up a 

 part of the external ring. The edge of the 

 rectus muscle extends itself laterally sufficiently 

 far to occupy one-half or one-third of the space 

 behind the external ring, and moreover here the 

 conjoined tendon is particularly strong. Not- 

 withstanding these supports, this part is weak ; 

 and yet when a hernia occurs here, it is not in 

 consequence of yielding or stretching, but be- 

 cause the conjoined tendon actually undergoes 

 laceration. 



The causes of this hernia are said to be three- 

 fold :J an unnatural weakness of the conjoined 

 tendon ; its absence altogether in consequence 

 of malformation ; and its being ruptured by 

 direct violence. Of these, the second is not 

 likely to occur, and an example of it had not 

 been met with by Sir A. Cooper at the time of 

 the publication of his work : the other two in 

 effect amount nearly to the same thing, or at 

 least stand towards each other in the relation of 

 a predisposing to an immediately exciting 



* The internal inguinal hernia of Hasselb.ich, 

 Jules Cloquet, and Velpeau : hernia on the inner 

 side of the epigastric artery of Sir A. Cooper, and 

 a combination of ventral and inguinal hernia ac- 

 cording to Scarpa. 



t This is frequently termed Colles's fascia, having 

 been first accurately described by that writer. 



} Cooper, p. 51. 



3D2 



