Inguinal Fossettes 311 



Hesselbach's triangle through which it has escaped. If it have 

 escaped close on the inner side of the artery, that is, between the 

 artery and the outer border of the conjoined tendon, the coverings 

 are just those of oblique hernia, only the fascia transversalis taken 

 in front of it will not be the c infundibuliform process,' as that is the 

 piece of the fascia which specially surrounds the cord. A direct 

 hernia emerges on the inner side of the cord, and its neck is close 

 over the pubes, whilst the oblique runs as a pyriform mass from 

 above the middle of Poupart's ligament. On reducing a direct 

 hernia the external border of the rectus can be made out close on 

 the inner side of the short straight passage by which the protrusion 

 emerged. 



If the direct hernia pass out nearer to the border of the rectus, it 

 bursts through the conjoined tendon, or carries it in front ; the cover- 

 ings are then peritoneum (the sac), subperitoneal fat, transversalis fascia, 

 conjoined tendon (unless it have passed through it), intercolumnar 

 fascia, superficial fasciae, and skin. This hernia pushes straight 

 through the abdominal wall, and occupies but the lowest and inner- 

 most part of the inguinal canal. It cannot take a twofold investment 

 from the internal oblique it takes the internal oblique in the form of 

 conjoined tendon, instead of the cremaster. 



The inguinal fossettes are three depressions in the inguinal 

 piece of the parietal peritoneum, caused by the ridge-like elevations 

 over the obliterated hypogastric and the deep epigastric (p. 306) 

 arteries. The innermost fossette is between the outer border of the 

 rectus and the ridge of the hypogastric artery ; the middle one is 

 between that ridge and the elevation caused by the epigastric artery, 

 and the outermost is external to the epigastric ridge behind the in- 

 ternal abdominal ring. The external direct hernia passes through the 

 middle fossette, and the internal direct through the innermost. 



The seat of stricture in an oblique inguinal hernia may be at 

 the external or internal abdominal ring, in which case the protrusion 

 may be returnable after division of the external oblique aponeurosis, 

 or the transversalis fascia, and without opening the peritoneal sac. 

 But the strangulation is almost invariably in the narrow neck of the 

 peritoneal sac itself, so that the operator generally has to open the sac ; 

 in doing this, discoloured serum escapes ; he then sees the bowel, 

 congested or plum-coloured, or black and gangrenous. Introducing 

 a strong, narrow, probe-pointed knife, on the flat, and turning its edge 

 against the constricting band, he makes a small incision directly 

 tip-wards. Thus he is sure of avoiding the epigastric artery, which 

 would be wounded if, in operating on a direct hernia, he were to cut 

 outwards, or, in an oblique hernia, inwards. As he does not always 

 know on which side of the artery the hernia has emerged, the rule to 

 cut upwards is invariable. Generally he can recognise a direct hernia 

 by its forming a rounded protrusion over the pubes. But an oblique 



