DIRECT IXGUIXAL IIEKNTA. 



1027 



Direct inguinal hernia (internal : ventro-iuguinal). Instead of following 

 the whole course of the inguinal canal, in the manner of the hernia above 

 described, the viscus in this case is protruded from the abdomen to the 

 groin directly through the lower end of the canal, at the external abdominal 

 ring ; and at this point the two forms of hernia, if they co-existed, would 

 come together. At the part of the abdominal wall through which the direct 

 inguinal hernia finds its way, there is recognised on its posterior aspect a 

 triangular interval, the sides of which are formed by the epigastric artery, 

 and the margin of the rectus muscle, and the base by Poupart's ligament. 

 It is commonly named the triangle of Hesselbach. Through this space the 

 hernia is protruded, carrying before it a sac from the internal fossa of the 

 peritoneum ; and it is in general forced onwards directly into the external 

 abdominal ring. 



Fig. 708. INTERNAL VIEW OF THE 

 VESSELS RELATED TO THE GROIN. 



A portion of the wall of the abdo- 

 men and the pelvis is here seen on the 

 posterior aspect, the os innominatum 

 of the left side and the soft parts con- 

 nected with it having been removed 

 from the rest of the body. 1, symphysis 

 of the pubes ; 2, irregular surface of 

 the hip-bone which has been separated 

 from the sacrum ; 3, ischial spine ; 4, 

 ischial tuberosity ; 5, obturator inter- 

 nus ; 6, rectus, covered with an elonga- 

 tion from 7, fascia transversalis ; 8, 

 fascia iliaca covering the iliacus muscle ; 

 9, psoas magnus cut ; 10, iliac artery ; 

 11, iliac vein ; 12, epigastric artery and 

 its two accompanying veins ; 1 3, vessels 

 of the spermatic cord, entering the abdo- 

 minal wall at the internal ring. The 

 ring was in this case of small size ; 14, 

 two obturator veins ; 15, the obi iterated 

 umbilical artery. The cord, it will be 

 remembered, is not naturally in contact 

 with the abdominal parietes in this 

 situation. 



The coverings of this hernia, taking them in the crder in which they are 

 successively applied to the protruded viscus, are the following : The peri- 

 toneal sac ahd the subserous membrane which adheres to it, the fascia 

 transversalis, the tendon common to the internal oblique and transverse 

 muscles, and the intercolumnar (external spermatic) fascia derived from the 

 margin of the external abdominal ring, together with the superficial fascia 

 and the integuments. 



With respect to one of the structures enumerated, namely, the common 

 tendon of the two deeper muscles, considerable variety exists as to its 

 disposition in different cases. In place of being covered by that tendon, 

 the hernia may be found to pass through an opening in its fibres, or to 

 escape beneath it. Cremasteric muscular fibres are met with (rarely, how- 

 ever,) upon this hernia. 



The spermatic cord is commonly placed behind the outer part of the 

 direct inguinal hernia, especially at the external abdominal ring. It is 

 here that the hernia and the cord in most cases first come together ; and 



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