operation be required in this form, the testicle is not seen as in the congenital.

4. The encysted congenital (Fig. 187). In this form the funicular process of the tunica vaginalis is cut off from the peritoneal cavity by a septum at the internal ring. The septum yields to the pressure of the hernia, and becomes invaginated before it into the unobliterated funicular process. Should an operation be necessary, the anterior layer of the funicular process, and the elongated septum forming the spurious sac, will have to be cut through. Here, as in the funicular variety, the hernia is not in contact with the testicle.

5. The infantile hernia is one in which the intestine, enclosed in its sac, descends behind the funicular process of the tunica

vaginalis, which has remained unobliterated, but is cut off by a septum at the internal abdominal ring from the general peritoneal cavity. Should an operation become necessary, three layers of peritoneum have to be cut through, viz., the anterior layer of the unobliterated funicular process of the tunica vaginalis; the posterior layer of the same; and finally the true sac. The last two, however, are generally intimately blended, so that there are apparently only two layers to be cut through.

THE DIRECT OF INTERNAL INGUINAL hernia is so called because it escapes directly through the external abdominal ring without traversing the internal ring and the whole length of the canal, and is situated internal to the deep epigastric artery. Before

escaping at the external abdominal ring it either passes through or under the conjoined tendon of the internal oblique and transversalis, which is situated immediately behind the external abdominal ring; or it protrudes that structure in front of it. The coverings from without inward are, 1, skin; 2, superficial and deep fascia; 3, intercolumnar fascia; 4, transversalis fascia; 5, subperitoneal fat; and 6, peritoneum forming the sac. When the conjoined tendon is protruded in front of the hernia, this, of course, constitutes an additional covering, and will then be found between the intercolumnar and transversalis fascia. It will thus be seen that the coverings of the direct hernia differ from those of the oblique, in the absence in the former of the cremasteric fascia, and in the substitution of the transversalis for the infundibuliform fascia. The spermatic cord with its coverings of the cremasteric and infundibuliform fascia lies to the outer side. From what has been said above it will be seen that the epigastric artery is situated on the inner side of the neck of the sac in the oblique; on the outer side in the direct. The stricture when the hernia is strangulated will be situated at the external abdominal ring or at the aperture in the conjoined tendon through which the hernia has passed.

Two varieties of direct inguinal hernia are described according as the protrusion takes place internal or external to the obliterated hypogastric artery, but are not of sufficient importance to be described here.

Signs and Diagnosis of Inguinal Hernia.-There is a swelling in the inguinal region having the general characters of hernia already given. When incomplete the swelling will be in the groin, and has to be chiefly distinguished from a femoral hernia, enlarged inguinal glands, encysted hydrocele of the cord, nondescended testicle, abscess in the inguinal canal, and, in rare instances, from fatty and other tumors of the cord. When it is complete, i.e., has passed into the scrotum, the diagnosis has to be made from hydrocele of the tunica vaginalis, solid tumors of the testicle, and varicocele. 1. In enlarged glands the canal is free, the glands are felt in front of it, and some cause is present to account for their enlargement. 2. In femoral hernia the

swelling is external to the spine of the pubes, the neck of the hernia is below Poupart's ligament, the inguinal canal is free, but the hernia can be felt through its front wall, and to return it pressure must be made in a direction downward, backward, and then upward. In inguinal hernia, on the contrary, the swelling is internal to or over the spine of the pubes, the neck is above Poupart's ligament, the inguinal canal is occupied by it, and to return it pressure must be made upward and outward.

3. In encysted hydrocele of the cord the swelling is translucent, tense, oval, and well defined. There is no impulse on cough; and it cannot be returned into the abdomen. 4. In retained testicle that organ is absent from the scrotum; there is no impulse on cough; testicular sensation can be obtained on pressure on the swelling, and it cannot be returned into the abdomen. If the testicle is inflamed, vomiting may be present, but it has not the gushing character of the vomiting of hernia, and constipation, if also present, is not complete. There may, however, be a strangulated hernia in addition to an inflamed testicle. The diagnosis in such a case is very difficult. If in doubt, an exploratory incision should be made over the tumor. 5. In hydrocele of the tunica vaginalis the tumor is translucent, tense, and semi-fluctuating; there is absence of impulse on coughing, freedom of the cord, and a history of it having begun at the bottom of the scrotum. In infants, however, a hernia may be translucent, and in a hydrocele of the congenital variety the fluid can be pressed back into the abdomen, but it does not return with the gurgle or slip characteristic of a hernia. 6. In varicocele the dilated veins feel like a bag of worms in the scrotum, and the impulse on cough has a thrill-like character. A varicocele, like a hernia, is reduced on the patient lying down, but if the finger is placed firmly over the ring, the veins, on the patient rising, refill notwithstanding the pressure of the finger, whereas a hernia would remain reduced. The indirect hernia cannot practically be distinguished from the direct as the rings get dragged down opposite one another. The indirect is more

common in the young, the direct in the old.

Treatment. What has already been said on this subject with regard to hernia generally, is applicable here, and it need only be added that if an operation is necessary the stricture should be divided directly upward, so as to avoid the epigastric artery; and that when combined with retained testicle a truss should be worn, if practicable, above the testicle. If the truss causes the testicle to become frequently inflamed, the testicle had better be removed.

A FEMORAL HERNIA is one that escapes into the femoral sheath, and nearly always internal to the femoral vessels, though in very exceptional cases it has been found external to them. As a rule, it leaves the abdomen at the femoral ring, and after passing downward through the femoral canal, emerges at the saphenous opening, and then turning upward and outward over the falciform process of the fascia lata, passes, should it further increase in size, over Poupart's ligament on to the aponeurosis of the external oblique muscle of the abdomen. The neck of

the sac is situated at the femoral ring, and is therefore bounded in front by Poupart's ligament, behind by the bone, internally by the sharp wiry edge of Gimbernat's ligament, and externally by the femoral vein, from which it is only separated by the innermost septum of the femoral sheath. The spermatic cord is close above it; the epigastric artery passes a little external to it; but there is no structure of importance, as a rule, on its inner and upper and inner side. The obturator artery, however, may be given of from the epigastric or external iliac artery, and encircle this part of the ring in its course to the obturator foramen (Fig. 190). It is then in great danger of being wounded in dividing the stricture. Fortunately, however, although the artery often rises in this abnormal manner, it does not then, as

a rule, take the above-mentioned dangerous course, but passes along the outer side of the ring, where it is out of danger. The coverings of a femoral hernia are-(Fig. 191) 1, skin; 2, superficial fascia; 3, cribriform fascia; 4, anterior layer of the femoral sheath, called the fascia propria; 5, septum crurale; 6, subperitoneal fat; and 7, peritoneum forming the sac. The fascia propria is often very thin, or in places absorbed, so that little more than skin and one or two delicate layers of fascia cover the sac. But it may be greatly thickened, especially over the neck of the sac, where it may form distinct fibrous bands, which go by the name of the deep crural arch. Femoral hernia is never congenital; and seldom occurs before adult life. It is more common in women than in men. The stricture when the

hernia is strangulated is at the saphenous opening, at Gimbernat's ligament, or more rarely at the deep crural arch.

Signs and Diagnosis (Fig. 192).-A femoral hernia usually appears as a tense globular swelling at the upper and inner part of the thigh, just below Poupart's ligament internal to the femoral vessels, and external to the spine of the pubes. It is usually small, but may sometimes be as large as an orange, or even larger. It then extends upward and outward over Poupart's ligament toward the iliac spine, and appears as an elongated soft and yielding swelling with its long axis parallel to the ligament. Its neck, however, can always be traced below the ligaments toward the femoral ring. The characteristic signs of hernia are, of course, present.

The diagnosis has chiefly to be made from enlarged glands, varix of the saphenous vein, inguinal hernia, and psoas abscess.

1. In enlarged glands there is no impulse on cough; they can be raised from the deeper tissues, and there will probably be some evident cause, as a sore on the heel, etc., to account for them. A small piece of irreducible omentum, however, may almost exactly resemble an enlarged gland in the femoral canal; and it may be impossible to make a diagnosis without exploring the ring, an operation which should always be undertaken if symptoms of strangulation of the intestine are present. At times, there may be an enlarged gland over a hernia. 2. In varix of the saphena vein the vein is generally also varicose lower down the limb, and the impulse on coughing has a peculiar thrill-like character, and extends also some distance down the vein. When the swelling is reduced by placing the patient on his back, and the ring is closed by the finger, the vein refills when he rises,