PARTS CONCERNED IN INGUINAL HERNIA 1131 



contact with the lower surface of the hymen. \\'hen the fourdiette is i)ullcil down 

 by the finger, a shallow' depression is seen, the fossa navicularis, with tin- I'our- 

 chette for its ])osterior, and tiie hymen for its anterior houndary. 



Examination per vaginam. — The finger, introduced past the gluteal cleft, 

 perinjeuni, and fourchetle, comes \\\m\\ the elliptical orilice of the vagina, and notes 

 how far it is patulous or narrow; the ])resence or otlu-rwise of any spasm from the 

 adjacent muscles; then, passing into the canal itself, the ]iresence or absence of 

 rugte, a naturally moist, or a dry condition are observt-d. In the anterior wall the 

 cord-like track of the urethra can l)e detected; and further up than this, if a sound 

 be j)assed, the posterior wall of the bladder. The anterior wall of the vagina is two 

 to two and a half inches long. The posterior wall, three inches long, forms the 

 recto-vaginal septum, and through it any fieces present in the lx)wel are easily felt. 

 The cervix uteri is next felt for in tlie roof of the vagina, projecting downwards and 

 backwards in a line drawn from the umbilicus to the coccyx. Besides its direction, 

 its size, shape, mobility, and consistence should be noted. The os uteri should form 

 a dimi)le or hssure in the centre of the cervix. Of its two lips the posterior is the 

 thicker and more fleshy feeling of the two. The vaginal culs-de-sac or fornices are 

 next explored. These should l)e soft and elastic, giving an impression to the finger 

 similar to that when it is introduced into the angles of the mouth. Any resistance 

 felt here may he due to scars, swellings connected with the uterus (displacements, or 

 myomata), effusions of blood or inflammatory material, and, in the case of the 

 lateral culs-de-sac, a displaced or enlarged ovary, or dilatations of the Falloiiian 

 tubes. 



HERNIA 



PARTS CONCERNED IN INGUINAL HERNIA 



In inguinal hernia, as in femoral and umbilical, there is a weak spot in the 

 abdominal wall — one weakened for the needful passage of the testicle from within 

 to outside the abdomen. The parts immediately concerned are the two abdominal 

 rings, external and internal, and the canal. Now, it must be remembered at the 

 outset that the rings and canal are only potential — they do not exist as rings or 

 canal save when opened up by a hernia, or when so made by the scalpel. The 

 canal is merely an ol)lique slit or fiat-sided passage. The external and internal 

 rings are so intimately l)lended with the structures that pass through them, and so 

 filled by them, that they are potential rings only. 



EXTERNAL RING. — This is usually described as a ring: it is really only a 

 separation or gap in the aponeurosis of the external oblique, by which in the male 

 the testicle and cord, and in the female the round ligament by which the uterus is 

 kei)t tilted a little forwards, pass out from the al)domen. The size of this opening, 

 the development and strengtli of its sides or pillars, the fascia closing the ring — all 

 vary extremely. Formation : by divergence of two fa.^ciculi of the external oblicjue 

 aponeurosis. Boundaries : two pillars — (1) Internal, the smaller, attached to tlie 

 symphysis and blending with the suspensory ligament of the penis; (2) external, 

 stronger, attached to the ]iubic spine and blending with Pou]tart's ligament, and so 

 with the fascia lata. On this outer, stronger pillar rests th(; cord (and so the weight 

 of the testicle), or round ligament. Shape : triangular or elliptical, with the base 

 downwards and inwards towards the jmliie crest. 



Intercolumnar fascia. External spermatic fascia. — This, derived from the 

 lower part of the ai)oneurosis of the external oblitpie, ties th«' two ))illars together, 

 and, l)eing continuiMl over the cord, prevents there l)eing any ring here, unless 

 made with a scal})cl. This is the rule in the l)ody: when any structure passes 

 throutih an opening in a rtl)rous or nuiscular layer, it carries with it a coating 

 of tissue from that layer; e.g. the inferior cava passing through the foramen 



