Anatomy, Surgical and topographical -- Atlases; Surgery -- Atlases; Surgery, Operative -- Atlases
Returning, however, to the more frequent conditions of inguinal
hernia--viz., those in which either the direct or the oblique variety
occurs alone--it should be remembered that a hernia originally oblique,
H, Plates 35 and 37, may, when of long standing, and having attained a
large size, destroy, by its gravitation, the obliquity of the inguinal
canal to such a degree as to bring the internal, H, Plate 35, opposite
to the external ring, as at I, and thereby exhibit all the appearance of
a hernia originally direct, I, Plate 37. In such a case, the epigastric
artery, F, which lies on the outer side of the neck of a truly direct
hernia, I, Plate 37, will be found to course on the inner side, G, of
the neck of this false-seeming direct hernia, I, Plate 35.
In the trial made for replacing the protruded bowel by the taxis, two
circumstances should be remembered in order to facilitate this object:
1st, the abdominal parietes should be relaxed by supporting the trunk
forward, and at the same time flexing the thigh on the trunk; 2nd, as
every complete hernial protrusion becomes distended more or less beyond
the seat of stricture--wherever this may happen to be--its reduction by
the taxis should be attempted, with gradual, gentle, equable pressure,
so that the sac may be first emptied of its fluid. That part of the
hernia which protruded last should be replaced first. The direction in
which the hernia protrudes must always determine the direction in which
it is to be reduced. If it be the external or oblique variety, the
viscus is to be pushed upwards, outwards, and backwards; if it be the
internal or direct variety, it is to be reduced by pressure, made
upwards and backwards. Pressure made in this latter direction will serve
for the reduction of that hernia which, from being originally external
and oblique, has assumed the usual position of the internal or direct
variety.
The seat of the stricture in an external inguinal hernia is found to be
situated either at the internal ring, corresponding to the neck of the
sac, or at the external ring. Between these two points, which "bound the
canal," and which are to be regarded merely as passive agents in causing
stricture of the protruding bowel, the lower parts of the transversalis
and internal oblique muscles embrace the herniary sac, and are known at
times to be the cause of its active strangulation or spasm.
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