VARIETIES OF INGUINAL HERNIA. 1029 



a change, namely, from the internal fossa to the external one. The 

 alteration of the fossa does not, however, in all cases coincide with a change 

 in the position of the hernia ; for the cord remaining from the obliteration 

 of the umbilical artery, (which separates the fossae,) instead of crossing 

 behind the triangle of Hesselbach so as to leave room at each side of it 

 for a hernia to penetrate that space, lies, it has been already stated, some- 

 times directly behind the epigastric artery : indeed, according to the 

 observations of Cloquet, it is most frequently in this position ;* and when 

 the cord in question is so placed, the hernia, whatever may be its position 

 in the triangle of Hesselbach, can occupy only the internal peritoneal fossa. 

 The inference, however, most important in a practical or surgical point of 

 view, to be drawn from the varying position of the neck of the internal 

 hernia, has reference not to the cord just alluded to, but to the epigastric 

 artery i. e. to the greater or less distance of the neck of the sac from that 

 vessel. 



The investments of the internal hernia are likewise liable to be influenced 

 by the position at which it penetrates the abdominal wall. It is in all 

 likelihood when the protrusion occurs outside the ordinary situation, that 

 the hernia escapes beneath the conjoined tendon of the two deeper muscles. 

 It is, moreover, under the same circumstances that the hernia is more 

 directly in front of the spermatic cord, and that the cremasteric fibres are 

 among its investments. (Ellis.) 



The internal inguinal hernia is very rarely met with in the female. In 

 the single example of the disease observed by Richard Quaiu, as well as 

 in the cases (a very small number) found recorded iu books, the hernia, 

 though not inconsiderable in size, was still covered with the tendon of the 

 external oblique muscle, f 



Distinctive diagnosis of oblique and direct inguinal hernice. The following 

 circumstances, which are brought together from the facts detailed in the 

 preceding pages, or are inferences from those facts, will serve to distin- 

 guish the two forms of the disease from one another. The oblique hernia, 

 when recently formed, is elongated and narrow at its upper part, being 

 restrained by the tendon of the external oblique muscle. It is, however, 

 attended with a degree of fulness in the inguinal canal, as well as tender- 

 ness upon pressure being made over the canal. After passing through the 

 external abdominal ring, it is observed to be directly in front of the 

 spermatic cord. The direct hernia, when of small size, is globular ; it is 

 protruded more immediately over the pubes ; causes no fulness or tender- 

 ness in the canal ; and the spermatic cord is usually behind its outer side. 

 But the distinction between the two heruise admits of being made only 

 when the disease is recent and the tumour moderate in size ; for, when 

 oblique inguinal hernia is of long standing, and has attained considerable 



* Recherches, &c., p. 39, note. 



t See "Treatise on Ruptures," by Mr. Lawrence, 4th edit. p. 213, and an essay by 

 M. Velpeau in "Aunales de Chirurgie Franchise et etrangere," torn. i. p. 352. 



M. Velpeau, in the essay just referred to, proposes to recognise three varieties of 

 internal hernia, viz., 1, the ordinary form which passes straight through the external 

 abdominal ring ; 2, an outer oblique variety, which passes through a part of the inguinal 

 canal ; and 3, an inner oblique one, which entering the abdominal wall close to the edge 

 of the rectus muscle, is directed outwards in order to reach the opening in the external 

 oblique muscle. The first two forms adverted to by M. Velpeau have been described in 

 the text. With respect to the third variety or class sought to be introduced by that 

 surgeon, it should be observed that he seems to have been led to propose it by the 

 observation of a single case an example of internal hernia in the female. 



