INGUINAL HERNIA. 



75 



ternal ring, and there receives an investment from the superficial 

 fascia and the skin. We thus see that the intestine is covered by a 

 representation of all the structures forming the parietes of the abdo- 

 men, with the exception of the external oblique muscle. 



Direct^ or ventro-inguiJial hernia^ is a protrusion at the external 

 abdominal ring, having its coverings formed in very much the same 

 manner as the last, but instead of the cremaster muscle forming a 

 covering, it is covered by the expanded tendon of the internal oblique 

 and transversalis muscles. Sometimes this tendon is split, and there 

 is no covering representing this portion of the parietes of the abdo- 

 men. The tumour in this variety is nearer the symphysis pubis, 

 and is on the inner side of the epigastric artery, whereas, in the 

 direct variety, the tumour is on the other side of the epigastric 

 artery. 



Concealed inguinal hernia is a term applied to a protrusion which 

 has been detained in the inguinal canal. 



The operation for relieving the stricture in an indirect inguinal 

 hernia is to be performed by placing the patient upon the edge of a 



Fig. 20. 



table, with each foot resting upon a • chair ; the surgeon sits before 

 him, and makes an incision extending from the upper part of the 

 tumour nearly to its base. The skin having been divided, the su- 

 perficial fascia must next be divided. This will be found to exist in 

 the form of laminae, the most inferior of which is the thickest ; having 

 been, in the natural condition of the parts, that portion of the fascia 

 which fills up the space between the columns of the external ring, 

 and which is sometimes called the intercolumnar fascia. After 

 this division the cremaster muscle will be exposed, altered from its 

 natural appearance ; the fibres being stretched and separated from 

 each other, and being more pallid than natural. Having divided 



