1394 CLINICAL AND TOPOGRAPHICAL ANATOMY 



The lyviphalics of the ovary follow the ovarian veins (see p. 745). 



Supports of the uterus. — The great mobility of the body of the uterus has been referred 

 to above. The organ derives its support almost entirely from the attachments of the cervix 

 and vaginal fornices. These rest on the pelvic floor, formed by the levator ani and perineal 

 body which support them the more efficiently since the long axis of the vagina is at right angles 

 to that of the uterus. Above the pelvic diaphragm the cervix is held up to the pelvic walls by 

 strong speciaUsed bands of fibro-muscular tissue running in both antero-posterior and trans- 

 verse directions. The chief of these, l3'ing in the base of the broad ligaments is a fibrous sheath 

 surrounding the uterine artery as it descends medially from the hypogastric. In the antero- 

 posterior direction the utero-vesical ligaments hold up the cervix to the pubes in front and the 

 sacro-uterine hgaments bind it to the anterior aspect of the sacrum behiind. While firmly 

 supporting the uterus these bands are elastic, and so do not fix it rigidly, but allow of the cervix 

 being drawn downward by traction with vulsellum forceps. 



For lymphatics of uterus and vagina see p. 745. 



The ureter.^ — The pelvic portion of this duct is of special importance in opera- 

 tions on the uterus and upper vagina. It crosses the brim of the pelvis on either 

 side at the bifurcation of the common iliac artery, or just in front of it, and 

 descends on the side wall in front of the hypogastric artery, crossing the ob- 

 literated umbilical and obturator arteries. Curving forward and medially it 

 passes under the base of the broad ligament, where the uterine artery crosses 

 above it, and so gains the lateral angle of the bladder by passing across in rela- 

 tion to the lateral fornix of the vagina. In the base of the broad ligament the 

 ureter lies about 2 cm. (| in.) from the side of the cervix, and this relation must 

 be borne in mind in excision of the uterus. 



Pelvic floor. — The pelvic floor of the female corresponds in general to that 

 of the male (see p. 1383). There are, however, important differences, due to the 

 sexual organs. The urogenital diaphragm is relatively smaller in area, due to per- 

 foration by the vagina. The pelvic diaphragm is also correspondingly modified, 

 and the pubo-coccygeus component is more strongly developed (see section on 

 Musculature.) The ischio-rectal fossa is similar to that of the male (p. 1384). 



HERNIA 



Three varieties of hernia will be considered, inguinal, femoral, and umbilical 



PARTS CONCERNED IN INGUINAL HERNIA 



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

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

 to outside the abdomen (p. 1387). The parts immediately concerned are the two 

 inguinal rings, subcutaneous (external) and abdominal (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 oblique slit or flat-sided 

 passage. The subcutaneous and abdominal rings are so intimately blended with 

 the structures that pass through them, and so filled by them, that they are potential 

 rings only. 



The subcutaneous inguinal (external abdominal) 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 kept tilted a little foward, pass out 

 from the abdomen. The size of this opening, the development and strength of its 

 crura or pillars, the fascia closing the ring — all vary extremely. Formation : by 

 divergence of two fasciculi of the external oblique aponeurosis. Boundaries : two 

 crura — (1) Superior, the smaller, attached to the symphysis and l)lcnding with the 

 suspensory ligament of the penis; (2) inferior, stronger, attached to the pubic 

 tubercle and blending with the inguinal ligament, and so with the fascia lata. On 

 this inferior, stronger crus rests the cord (and so the weight of the testicle) or 

 round ligament. Shape : triangular or elliptical, with the base downward and 

 meflially toward the pubic crest. 



Intercrural fibres (intercolumnar fascia) (external spermatic fascia). — This, derived from 

 the lower jmrt of tlic apoiHiurosis of the oxtcriial obli(iue, ties tlic two criu-a together, and, being 

 continued over the cord, prevents there being any ring here, unless made with a scalpel. This 

 is the rule in the body: when any structure passes through an opening in a fibrous or muscular 



