723 
SURGERY. 
accurate observers, its commencement is generally slow 
and gradual, it afterwards frequently undergoes a sudden 
enlargement, and is for the first time particularly noticed 
by the patient himself, after he has been making some violent 
effort. 
“ 2. By the diminution, or even total disappearance of 
the swelling, when the patient lies upon his back; by its 
recurrence, when he stands up again; and by the im¬ 
pulse which is felt in the swelling, whenever the patient 
coughs.” 
The inguinal hernia passes out of the internal abdominal 
ring, or, in other words, beneath the united tendon of the 
internal oblique and transversalis muscles. It afterwards 
lies in the inguinal canal, and ultimately passes out at the 
external abdominal ring. It will be recollected that the 
external ring is considerably nearer the pubis than the inter¬ 
nal ring; but in a hernia of any duration the rings become 
so far dilated, that they are nearly opposite to one another. 
When a hernia is strangulated, it is in a few instances con¬ 
stricted at the external abdominal ring. These are generally 
old cases. The commonest situation is at the internal ring 
which is found about an inch deeper than the outer ring. 
But when the hernia is very small, and the parts consequently 
not much displaced, the stricture is found as deeply situated 
as two inches. Occasionally a membranous band forms 
•across the neck of the sac, which produces the stricture, and 
this is generally very remote. The coverings of inguinal 
hernia are the peritoneum which forms the sac, the'cremaster 
muscle which is expanded and thickened, the fascia superfici- 
alis and the common integuments. The epigastric artery is 
behind and to the inner side of the hernia. 
There is a sort of hernia which Sir A. Cooper calls direct, 
and Hesselbach internal. Instead of coming through the 
internal abdominal ring, it passes, as Scarpa very clearly ex¬ 
plains, through a fissure in the muscle which is nearer the pu¬ 
bis than that ring. Consequently it passes nearly straight out¬ 
wards to the external ring, and of course leaves the epigastric 
artery on its outer side. Now Sir A. Cooper states that this 
direct sort of hernia has one more covering than the oblique 
hernia, namely, a fascia protruded before it that is derived from 
the fascia transversalis, and transversalis muscle. 
Hernia of the Tunica Vaginalis.—“ This case differs from 
all other ruptures in the circumstance of the protruded 
bowels being in immediate contact with the testicle, the 
tunica vaginalis serviug as the hernial sac. Or, (to use the 
words of Richter), the displaced bowel and the testicle, 
simply covered by its albuginea, lie together in one and the 
same sac.” 
The origin of this species of hernia is as follows: until 
the approach of birth, the testes of the foetus are lodged 
within the cavity of the abdomen, and situated immediately 
below the kidneys, on the fore-part of the psoas muscles, by 
the side of the rectum, which bowel is larger in proportion to 
the capacity of the pelvis than in the full-grown subject, and 
lies before the lumbar vertebrae as well as the os sacrum. 
The anterior and lateral surfaces of the testis are covered by 
reflected peritonaeum, while posteriorly it adheres to the 
psoas muscle by means of cellular substance. A little while 
before birth, generally in the eighth month, but sometimes 
subsequently to this event, the testes descend through the 
abdominal ring, and then pass through a kind of membra¬ 
nous canal, which the peritonaeum forms from that aperture 
into the scrotum. Thus, as they were already furnished with 
one peritoneal investment up in the loins, a second is ac¬ 
quired by their entering this canal, or rather elongation of 
the peritonaeum. The first covering, which is smooth, and 
every where closely adherent to the surface of the testis, con¬ 
stitutes the tunica albuginea; while the other, which is 
denser, and in front loose and unconnected, becomes the 
tunica vaginalis. Now it is into this production of perito¬ 
naeum (originally formed, and placed ready for the recep¬ 
tion of the testes on their descent from the loins), that the 
bowels are sometimes accidentally propelled, before the pas¬ 
sage leading into it from the belly is duly closed. The con¬ 
genital inguinal hernia, therefore, differs from the generality 
of ruptures in having no hernial sac, formed and produced 
by the peritonaeum being thrust forth from the belly by the 
displaced bowels themselves. There is, however, one un¬ 
common species of hernia which, in the tunica vaginalis, is 
included also in a common hernial sac, so that the protruded 
bowels neither lie in contact with the preceding membrane, 
nor with the albuginea. It seems to be formed, after the 
communication of the cavity of the peritonaeum with that of 
the tunica vaginalis has been obliterated, but previously to 
the closure of the passage lower down. 
“ The most important symptom, by which a congenital 
inguinal hernia may be distinguished from a common scrotal 
rupture, is the situation of the testis, which, in the latter dis¬ 
ease, can always be plainly felt towards the lower and back 
part of the tumor. But, in a congenital hernia, if the pro¬ 
trusion be at all considerable, the testis cannot be felt while 
the bowels are down. In a congenital hernia, the viscera 
usually pass from the groin down into the scrotum in a very 
short space of time, and, as it were, precipitately; but, in a 
common inguinal hernia, the protrusion is generally slower 
and more gradual. However, we may consider the quick¬ 
ness with which the bowels have descended from the groin 
into the scrotum, as a characteristic mark of a congenital 
hernia. 
The femoral or crural hernia is that to which women are 
most liable. It seldom occurs in male subjects, who, on 
the other hand, are very subject to bubonoceles, from which 
females are almost entirely exempt. It consists of a pro¬ 
trusion of some of the abdominal viscera under the pubic 
extremity of Poupart’s ligament. It rarely acquires a large 
size, and is generally of a globular shape, while an inguinal 
hernia is more or less oblong. Anatomical examinations 
prove, that the aperture through which the parts escape is 
exceedingly small, and hence, we must not be surprised at 
the remarkable rapidity with which the symptoms usually 
advance. 
In this hernia we find that the viscera are protruded 
through the crural ring, which lies under the crural arch, 
between its thin edge and the external iliac veins. A pro¬ 
trusion of the viscera, under any other part of the tendon, 
is prevented by the attachment of the iliac fascia. The 
hernia, having passed through the crural ring, rises above its 
edge, and therefore, as Mr. Hey has observed, if a surgeon 
attempts to reduce it when strangulated, by pushing it up¬ 
wards, he effectually frustrates his intention. The viscera 
descend from the abdomen at first nearly in a perpendicular 
direction, and come into the hollow in front of the pec- 
tineus. They then come forwards to the surface, so as to 
lie in general in front of the crural arch. The neck of the 
sac, or that portion of it lying under Poupart’s ligament, is 
generally about half an inch in length, and it is obvious that 
the strangulation must have a very deep situation, since it 
occurs exactly where the neck of the sac communicates with 
the abdomen. The tumour is situated in front of the pec- 
tineus, and of the fascia lata. There is one variety of femoral 
hernia, and in which the parts descend into the sheath of 
of the crural vessels. In this case the tumour is situated 
under the fascia lata, is more obscure to the feel, and has 
not a defined edge. 
The femoral hernia is usually of a rounder form, and less 
bulk when strangulated, than the scrotal hernia. Mr. Hey 
has repeatedly seen it resembling an enlarged inguinal gland. 
It is apt also to extend in a horizontal rather than a vertical 
direction. 
The femoral hernia is liable to be mistaken for a bubo¬ 
nocele. The cases may always be discriminated by recol¬ 
lecting, that if the swelling of a crural hernia be drawn 
downwards, the crural arch may be traced passing over the 
neck of the sac, while in bubonocele it extends under that 
part. The spine of the os pubis, which is behind and below 
the neck of the sac in an inguinal hernia, is on the same 
horizontal level, and rather within it in the crural rupture. 
A varix of the femoral vein may be distinguished from a 
crural hernia by the disappearance of the swelling on the 
patient’s lying down, and its recurrence again as soon as the 
vein 
