756 



HERNIA. 



The hernia by direct descent is distinguished 

 from the oblique, 1st, by the appearance of the 

 groin, the apex of the tumour being at the 

 situation of the external ring, and there being 

 no enlargement whatever in the direction of the 

 inguinal canal : this diagnostic, however, has 

 been found fallacious, for in old oblique hernia 

 the internal ring is dragged down and made to 

 approach the external so as to appear to form 

 one continuous opening. Nor is it easy to 

 point out the difference even in dissection ex- 

 cept by the position of the epigastric artery, 

 which in case of oblique descent always lies to 

 the pubic side of the neck of the sac. The 

 neck in some of these cases appears to be 

 arched over and strongly constricted by the 

 superior portion of the ruptured conjoined 

 tendon, which in these cases is more than 

 usually developed, and (as it were) in a state of 

 hypertrophy. It was probably this appearance 

 th;Lt led to a belief that strangulation was occa- 

 sionally produced by the action of these mus- 

 cles. '2nd, By the relative position of the 

 tumour with respect to the different structures 

 composing the cord. The cremaster muscle in 

 any hernia cannot be felt, but it occupies nearly 

 its usual position in this, being spread out like 

 a fascia in front of it, but rather towards its 

 outside. The spermatic cord properly so called 

 passes on its external rather than on its pos- 

 terior side; and although all its constituent 

 vessels may be separated in this as in any other 

 species of large and old herniae, yet generally 

 there is less divarication in this, and the parts 

 lie together more compactly. 3rd, " This 

 tumour differs from the common bubonocele in 

 being situated nearer the penis.' 7 * This is cer- 

 tainly true when it is only bubonocele; but 

 when it has descended into the scrotum, the 

 same difficulty that has been noticed as apper- 

 taining to old ruptures must also obtain here. 

 In applying this diagnostic the student must 

 recollect that the internal edges of both herniae 

 are equally near to the pubis : it is by looking 

 to the external border of the neck of the tumour 

 that he can render the test available. Scarpaf 

 states that this hernia is returned without being 

 attended by the gurgling sound : this, however, 

 is an observation perfectly new to me, and 

 which I can by no means verify. Lastly, these 

 hernise appear more suddenly and attain a larger 

 size more rapidly : frequently they appear as scrotal 

 ruptures almost from the earliest period. This, 

 however, is still an uncertain criterion, and in- 

 deed with the assistance of all these circum- 

 stances it is always so difficult and frequently 

 so utterly impossible to establish a diagnosis, 

 that no operation should be undertaken under 

 the conviction of the disease being certainly of 

 one form or of the other. 



This rupture should present to the anatomist 

 the same number of layers of fascia as that by 

 the oblique descent, the fascia transversalis sup- 

 plying the place of that given off from the edges 

 of the internal ring; J but the young surgeon 



* Cooper. 



t Scarpa, op. citat. p. 84. 



$ The internal spout-like fascia. 



should be cautioned not to expect the same 

 facilities of demonstration in the living subject 

 that he possesses in the dead. In the former, 

 the operator often meets with layer after layer 

 of fascia, numerous beyond his expectation, and 

 to which he can give no name ; and it is no un- 

 common circumstance for him to operate on 

 and return a rupture without being able to say 

 of what nature it was nay, even as to its being 

 inguinal or crural. 



CRURAL OR FEMORAL HERNIA takes place 

 at the superior and internal part of the thigh, 

 below the fold of the groin ; the intestine pass- 

 ing out of the abdomen behind Poupart's liga- 

 ment, between it and the transverse ramus of 

 the pubis, through an aperture that has been 

 termed the crural or femoral ring. A know- 

 ledge of the constitution, size, and boundaries 

 of this ring must be of the last importance to 

 the practical surgeon, and accordingly no part 

 of the body has been examined with more 

 minute attention ; yet if by these labours ana- 

 tomy has gained in accuracy of information and 

 very diffuse description, still the student is not 

 much the better for it, inasmuch as almost 

 every anatomist has adopted views peculiar to 

 himself, and thus in the details a degree of con- 

 fusion has been produced that is extremely em- 

 barrassing to the beginner. I shall, therefore, 

 avail myself as little as possible of authorities, 

 and endeavour to describe these parts as they 

 appear upon dissection, commencing from 

 within, which is perhaps the best mode of 

 studying the anatomy of every species of 

 hernia. 



The distance between the anterior superior 

 spinous process of the ileum and the angle of 

 the crest of the pubis is in the well-formed 

 female about five and a half inches in length, 

 along which space Poupart's ligament is 

 stretched like a bow-string from point to point. 

 The distance from the ligament thus extended, 

 backwards to the edges of the ileum and pubis 

 forming the border of the pelvis, varies accord- 

 ing to the elevations and depressions of these 

 bones ; but the entire forms a very considerable 

 space, which is, however, in general so well 

 filled up that unless under ^peculiar circum- 

 stances this region affords sufficient support 

 and protection to the viscera of the abdomen. 

 On examining the corresponding peritoneal sur- 

 face within, the membrane is found capable of 

 being detruded only at one spot, internal to the 

 view, and about an inch and a half distant from 

 the symphysis pubis. Here, there is a natural 

 aperture varying in size in different subjects, 

 into which the finger may be pushed by a little 

 violence, and a small artificial hernial sac like 

 a thimble be thus produced. On tearing off 

 the peritoneum it is easy to observe the dif- 

 ferent arrangements that serve to support and 

 strengthen this region of the abdomen. 



From Poupart's ligament three distinct layers 

 of fascia pass off in different directions. The 

 fascia transversalis has been already described 

 as passing upwards on the front of the abdomen, 

 where it is gradually lost. From the inferior 

 and posterior part of the arch another fascia 

 passes, at first downwards, then upwards and 



