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Demonstrations Of The Origin And Progress Of Inguinal Herniae In General






Source: Surgical Anatomy

PLATE 41, Fig. 1.--When the serous spermatic tube is obliterated for its
whole length between the internal ring, 1, and the top of the testicle,
13, a hernia, in order to enter the inguinal canal, 1, 4, must either
rupture the peritonaeum at the point 1, or dilate this membrane before
it in the form of a sac. [Footnote] If the peritonaeum at the point 1 be
ruptured by the intestine, this latter will enter the fibrous spermatic
tube, 2, 3, and will pass along this tube devoid of the serous sac. If,
on the other hand, the intestine dilates the serous membrane at the
point, 1, where it stretches across the internal ring, it will, on
entering the fibrous tube, (infundibuliform fascia,) be found invested
by a sac of the peritonaeum, which it dilates and pouches before itself.
As the epigastric artery, 9, bends in general along the internal border
of the ring of the fibrous tube, 2, 2, the neck of the hernial sac which
enters the ring at a point external to the artery must be external to
it, and remain so despite all further changes in the form, position, and
dimensions of the hernia. And as this hernia enters the ring at a point
anterior to the spermatic vessels, its neck must be anterior to them.
Again, if the bowel be invested by a serous sac, formed of the
peritonaeum at the point 1, the neck of such sac must intervene between
the protruding bowel and the epigastric and spermatic vessels. But if
the intestine enter the ring of the fibrous tube, 2, 2, by having
ruptured the peritonaeum at the point 1, then the naked intestine will
lie in immediate contact with these vessels.

[Footnote: Mr. Lawrence (op. cit.) remarks, "When we consider the
texture of the peritonaeum, and the mode of its connexion to the
abdominal parietes, we cannot fancy the possibility of tearing the
membrane by any attitude or motion." Cloquet and Scarpa have also
expressed themselves to the effect, that the peritonaeum suffers a
gradual distention before the protruding bowel.]


Abdomen, showing bone, blood vessels<br />
and other internal organs




PLATE 41, Fig. 2--When the serous spermatic tube, 11, remains pervious
between the internal ring, 1, (where it communicates with the general
peritonaeal membrane,) and the top of the testicle, (where it opens into
the tunica vaginalis,) the bowel enters this tube directly, without a
rupture of the peritonaeum at the point 1. This tube, therefore, becomes
one of the investments of the bowel. It is the serous sac, not formed by
the protruding bowel, but one already open to receive the bowel. This is
the condition necessary to the formation of congenital hernia. This
hernia must be one of the external oblique variety, because it enters
the open abdominal end of the infantile serous spermatic tube, which is
always external to the epigastric artery. Its position in regard to the
spermatic vessels is the same as that noticed in Fig, 1, Plate 41. But,
as the serous tube through which the congenital hernia descends, still
communicates with the tunica vaginalis, so will this form of hernia
enter this tunic, and thereby become different to all other herniae,
forasmuch as it will lie in immediate contact with the testicle.
[Footnote]

[Footnote: A hernia may be truly congenital, and yet the intestine may
not enter the tunica vaginalis. Thus, if the serous spermatic tube close
only at the top of the testicle, the bowel which traverses the open
internal inguinal ring and pervious tube will not enter the tunica
vaginalis.]


Abdomen, showing bone, blood vessels<br />
and other internal organs




PLATE 41, Fig. 3.--The infantile serous spermatic tube, 11, sometimes
remains pervious in the neighbourhood of the internal ring, 1, and a
narrow tapering process of the tube (the canal of Nuck) descends within
the fibrous tube, 2, 3, and lies in front of the spermatic vessels and
epigastric artery. Before this tube reaches the testicle, it degenerates
into a mere filament, and thus the tunica vaginalis has become separated
from it as a distinct sac. When the bowel enters the open abdominal end
of the serous tube, this latter becomes the hernial sac. It is not
possible to distinguish by any special character a hernia of this
nature, when already formed, from one which occurs in the condition of
parts proper to Fig. 1, Plate 41, or that which is described in the note
to Fig. 2, Plate 41; for when the intestine dilates the tube, 11, into
the form of a sac, this latter assumes the exact shape of the sac, as
noticed in Fig. 1, Plate 41. The hernia in question cannot enter the
tunica vaginalis. Its position in regard to the epigastric and spermatic
vessels is the same as that mentioned above.


Abdomen, showing bone, blood vessels<br />
and other internal organs



PLATE 41, Fig. 4.--If the serous spermatic tube, 11, be obliterated or
closed at the internal ring, 1, thus cutting off communication with the
general peritonaeal membrane; and if, at the same time, it remain
pervious from this point above to the tunica vaginalis below, then the
herniary bowel, when about to protrude at the point 1, must force and
dilate the peritonaeum, in order to form its sac anew, as stated of Fig.
1, Plate 41. Such a hernia does not enter either the serous tube or the
tunica vaginalis; but progresses from the point 1, in a distinct sac. In
this case, there will be found two sacs--one enclosing the bowel; and
another, consisting of the serous spermatic tube, still continuous with
the tunica vaginalis. This original state of the parts may, however,
suffer modification in two modes: 1st, if the bowel rupture the
peritonaeum at the point 1, it will enter the serous tube 11, and
descend through this into the cavity of the tunica vaginalis, as in the
congenital variety. 2nd, if the bowel rupture the peritonaeum near the
point 1, and does not enter the serous tube 11, nor the tunica
vaginalis, then the bowel will be found devoid of a proper serous sac,
while the serous tube and tunica vaginalis still exist in communication.
In either case, the hernia will hold the same relative position in
regard to the epigastric artery and spermatic vessels, as stated of Fig.
1, Plate 41.


Abdomen, showing bone, blood vessels<br />
and other internal organs



PLATE 41, Fig. 5.--Sudden rupture of the peritonaeum at the closed
internal serous ring, 1, though certainly not impossible, may yet be
stated as the exception to the rule in the formation of an external
inguinal hernia. The aphorism, "natura non facit saltus," is here
applicable. When the peritonaeum suffers dilatation at the internal
ring, 1, it advances gradatim and pari passu with the progress of the
protruding bowel, and assumes the form, character, position, and
dimensions of the inverted curved phases, marked 11, 11, till, from
having at first been a very shallow pouch, lying external to the
epigastric artery, 9, it advances through the inguinal canal to the
external ring, 4, and ultimately traverses this aperture, taking the
course of the fibrous tube, 3, down to the testicle in the scrotum.

Abdomen, showing bone, blood vessels<br />
and other internal organs




PLATE 41, Fig. 6.--When the bowel dilates the peritonaeum opposite the
internal ring, and carries a production of this membrane before it as
its sac, then the hernia will occupy the inguinal canal, and become
invested by all those structures which form the canal. These structures
are severally infundibuliform processes, so fashioned by the original
descent of the testicle; and, therefore, as the bowel follows the track
of the testicle, it becomes, of course, invested by the selfsame parts
in the selfsame manner. Thus, as the infundibuliform fascia, 2, 3,
contains the hernia and spermatic vessels, so does the cremaster muscle,
extending from the lower margins of the internal oblique and
transversalis, invest them also in an infundibuliform manner. [Footnote]


[Footnote: Much difference of opinion prevails as to the true relation
which the cord (and consequently the oblique hernia) bears to the lower
margins of the oblique and transverse muscles, and their cremasteric
prolongation. Mr. Guthrie (Inguinal and Femoral Hernia) has shown that
the fibres of the transversalis, as well as those of the internal
oblique, are penetrated by the cord. Albinus, Haller, Cloquet, Camper,
and Scarpa, record opinions from which it may be gathered that this
disposition of the parts is (with some exceptions) general. Sir Astley
Cooper describes the lower edge of the transversalis as curved all round
the internal ring and cord. From my own observations, coupled with
these, I am inclined to the belief that, instead of viewing these facts
as isolated and meaningless particulars, we should now fuse them into
the one idea expressed by the philosophic Carus, and adopted by Cloquet,
that the cremaster is a production of the abdominal muscles, formed
mechanically by the testicle, which in its descent dilates, penetrates,
and elongates their fibres.]


Abdomen, showing bone, blood vessels<br />
and other internal organs



PLATE 41. Fig. 7.--When an external inguinal hernia, 11, dilates and
protrudes the peritonaeum from the closed internal ring, 1, and descends
the inguinal canal and fibrous tube, 3, 3, it imitates, in most
respects, the original descent of the testicle. The difference between
both descents attaches alone to the mode in which they become covered by
the serous membrane; for the testicle passes through the internal ring
behind the inguinal peritonaeum, at the same time that it takes a
duplicature of this membrane; whereas the bowel encounters this part of
the peritonaeum from within, and in this mode becomes invested by it on
all sides. This figure also represents the form and relative position of
a hernia, as occurring in Figs. 1 and 3, 5, and 6, Plate 41.


Abdomen, showing bone, blood vessels<br />
and other internal organs




PLATE 41, Fig. 8.--When the serous spermatic tube only closes at the
internal ring, as seen at 1, Fig. 4, Plate 41, if a hernia afterwards
pouch the peritonaeum at this part, and enter the inguinal canal, we
shall then have the form of hernia, Fig. 8, Plate 41, termed infantile.
Two serous sacs will be here found, one within the cord, 13, and
communicating with the tunica vaginalis, the other, 11, containing the
bowel, and being received by inversion into the upper extremity of the
first. Thus the infantile serous canal, 13, receives the hernial sac,
11. The inguinal canal and cord may become multicapsular, as in Fig. 8,
from various causes, each capsule being a distinct serous membrane.
First, independent of hernial formation, the original serous tube may
become interruptedly obliterated, as in Plate 40, Fig. 2. Secondly,
these sacs may persist to adult age, and have a hernial sac added to
their number, whatever this may be. Thirdly, the original serous tube,
13, Fig. 8, may persist, and after having received the hernial sac, 11,
the bowel may have been reduced, leaving its sac behind it in the
inguinal canal; the neck of this sac may have been obliterated by the
pressure of a truss, a second hernia may protrude at the point 1, and
this may be received into the first hernial sac in the same manner as
the first was received into the original serous infantile tube. The
possibility of these occurrences is self-evident, even if they were
never as yet experienced. [Footnote]

[Footnote: According to Mr. Lawrence and M. Cloquet, most of the serous
cysts found around hernial tumours are ancient sacs obliterated at the
neck, and adhering to the new swelling (opera cit.)]


Abdomen, showing bone, blood vessels<br />
and other internal organs




PLATE 42, Fig. 1.--The epigastric artery, 9, being covered by the fascia
transversalis, can lend no support to the internal ring, 2, 2, nor to
the tube prolonged from it. The herniary bowel may, therefore, dilate
the peritonaeum immediately on the inner side of the artery, and enter
the inguinal canal. In this way the hernia, 11, although situated
internal to the epigastric artery, assumes an oblique course through the
canal, and thus closely simulates the external variety of inguinal
hernia, Fig. 7, Plate 41. If the hernia enter the canal, as represented
in Fig. 1, Plate 42, it becomes invested by the same structures, and
assumes the same position in respect to the spermatic vessels, as the
external hernia.


Abdomen and scrotum, showing bone, blood vessels<br />
and other internal organs




PLATE 42, Fig. 2.--The hernial sac, 11, which entered the ring of the
fibrous tube, 2, 2, at a point immediately internal to the epigastric
artery, 9, may, from having been at first oblique, as in Fig. 1, Plate
42, assume a direct position. In this case, the ring of the fibrous
tube, 2, 2, will be much widened; but the artery and spermatic vessels
will remain in their normal position, being in no wise affected by the
gravitating hernia. If the conjoined tendon, 6, be so weak as not to
resist the gravitating force of the hernia, the tendon will become bent
upon itself. If the umbilical cord, 10, be side by side with the
epigastric artery at the time that the hernia enters the mouth of the
fibrous tube, then, of course, the cord will be found external. If the
cord lie towards the pubes, apart from the vessel, the hernia may enter
the fibrous tube between the cord, 10, and artery, 9. [Footnote:] It is
impossible for any internal hernia to assume the congenital form,
because the neck of the original serous spermatic tube, 11, Fig. 2,
Plate 41, being external to the epigastric artery, 9, cannot be entered
by the hernia, which originates internally to this vessel.

[Footnote: M. Cloquet states that the umbilical cord is always found on
the inner side of the external hernia. Its position varies in respect to
the internal hernia, (op. cit. prop. 52.)]


Abdomen and scrotum, showing bone, blood vessels<br />
and other internal organs




PLATE 42, Fig. 3.--Every internal hernia, which does not rupture the
peritonaeum, carries forward a sac produced anew from this membrane,
whether the hernia enter the inguinal canal or not. But this is not the
case with respect to the fibrous membrane which forms the fascia
propria. If the hernia enter the inguinal wall immediately on the inner
side of the epigastric artery, Fig. 1, Plate 42, it passes direct into
the ring of the fibrous tube, 2, 2, already prepared to receive it. But
when the hernia, 11, Fig. 3, Plate 42, cleaves the conjoined tendon, 6,
6, then the artery, 9, and the tube, 2, 2, remain in their usual
position, while the bowel carries forward a new investment from the
transversalis fascia, 5, 5. That part of the conjoined tendon which
stands external to the hernia keeps the tube, 2, 2, in its proper place,
and separates it from the fold of the fascia which invests the hernial
sac. This is the only form in which an internal hernia can be said to be
absolutely distinct from the inguinal canal and spermatic vessels. This
hernia, when passing the external ring, 4, has the spermatic cord on its
outer side.

Abdomen and scrotum, showing bone, blood vessels<br />
and other internal organs




PLATE 42, Fig. 4.--The external hernia, from having been originally
oblique, may assume the position of a hernia originally internal and
direct. The change of place exhibited by this form of hernia does not
imply a change either in its original investments or in its position
with respect to the epigastric artery and spermatic vessels. The change
is merely caused by the weight and gravitation of the hernial mass,
which bends the epigastric artery, 9*, from its first position on the
inner margin of the internal ring, 1, till it assumes the place 9. In
consequence of this, the internal ring of the fascia transversalis, 2,
2, is considerably widened, as it is also in Fig. 2, Plate 42. It is the
inner margin of the fibrous ring which has suffered the pressure; and
thus the hernia now projects directly from behind forwards, through, 4,
the external ring. The conjoined tendon, 6, when weak, becomes bent upon
itself. The change of place performed by the gravitating hernia may
disturb the order and relative position of the spermatic vessels; but
these, as well as the hernia, still occupy the inguinal canal, and are
invested by the spermatic fascia, 3, 3. When an internal hernia, Fig. 1,
Plate 42, enters the inguinal canal, it also may descend the cord as far
as the testicle, and assume in respect to this gland the same position
as the external hernia. [Footnote]

[Footnote: As the external hernia, Fig. 4, Plate 42, may displace the
epigastric artery inwards, so may the internal hernia, Fig. 1, Plate 42,
displace the artery outwards. Mr. Lawrence, Sir Astley Cooper, Scarpa,
Hesselbach, and Langenbeck, state, however, that the internal hernia
does not disturb the artery from its usual position three-fourths of an
inch from the external ring.]

Abdomen and scrotum, showing bone, blood vessels<br />
and other internal organs




PLATE 42, Figs. 5, 6, 7.--The form and position of the inguinal canal
varies according to the sex and age of the individual. In early life,
Fig. 6, the internal ring is situated nearly opposite to the external
ring, 4. As the pelvis widens gradually in the advance to adult age,
Fig. 5, the canal becomes oblique as to position. This obliquity is
caused by a change of place, performed rather by the internal than the
external ring. [Footnote] The greater width of the female pelvis than of
the male, renders the canal more oblique in the former; and this,
combined with the circumstance that the female inguinal canal, Fig. 7,
merely transmits the round ligament, 14, accounts anatomically for the
fact, that this sex is less liable to the occurrence of rupture in this
situation.

[Footnote: M. Velpeau (Nouveaux Elemens de med. Operat.) states the
length of the inguinal canal in a well-formed adult, measured from the
internal to the external ring, to be 1-1/2 or 2 inches, and 3 inches
including the rings; but that in some individuals the rings are placed
nearly opposite; whilst in young subjects the two rings nearly always
correspond. When, in company with these facts, we recollect how much the
parts are liable to be disturbed in ruptures, it must be evident that
their relative position cannot be exactly ascertained by measurement,
from any given point whatever. The judgment alone must fix the general
average.]


Abdomen and scrotum, showing bone, blood vessels<br />
and other internal organs


Abdomen and scrotum, showing bone, blood vessels<br />
and other internal organs



Abdomen, showing bone, blood vessels<br />
and other internal organs






Next: The Dissection Of Femoral Hernia And The Seat Of Stricture

Previous: Demonstrations Of The Nature Of Congenital And Infantile Inguinal Herniae And Of Hydrocele



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