PRACTICAL CONSIDERATIONS : ABDOMINAL HERNIA. 1773 



Iliac crest 



Anterior 

 superior iliac 

 spine 



Muscular space 



Femoral hernia is more common in females than in males for reasons already 

 given (page 1762). It is always acquired, as the femoral "canal" is even less an 

 actual passage than is the inguinal canal. Its upper orifice (the femoral or crural ring) 

 (P'ig. 1493) is the weakest spot in that portion of the abdominal parietes represented 

 by the inner surface of the inguino-femoral region. The firm union of the trans- 

 versalis and iliac fasciae to the outer half of Poupart's ligament and the presence of 

 the ilio-psoas muscle enclosed in its osseo-fascial space {lacuna inusculorum) by the 

 ilium and the iliac fascia ol?er practically insuperable obstacles to the descent of 

 abdominal contents beneath Poupart's ligament external to the femoral vessels (Fig. 

 1496). Only a very few such cases have been reported. At the extreme inner angle 

 of the ilio-pubic space, bridged over by Poupart's ligament, the pectineus muscle, 

 covered by the pectineal fascia and Gimbernat's ligament, offers a similar resistance. 

 Between these two muscular compartments, however, lies the space occupied by the 

 great vessels of the lower extremity in their passage between their retroperitoneal 

 position in the abdomen and the thigh. This space — the vascular compartment 

 {Ij.ama vasorum) — is only partially occupied by the vessels. Their sheath is made 

 up by the lateral union, externally and internally, of the transversalis fascia anteriorly 

 and the iliac fascia pos- 

 teriorly. This sheath Fig. 1496. 

 does not embrace the 

 vessels closely until it 

 descends from one-half 

 to three-quarters of an 

 inch below the rela- 

 tively unyielding Pou- 

 part's ligament, about 

 opposite the upper 

 margin of the saphe- 

 nous opening, — /. e. , 

 to a point at which, in 

 the movements of flex- 

 ion and extension of the 

 thigh on the abdomen, 

 the vessels are less lia- 

 ble to injurious traction 

 or compression. It is 

 therefore infundibuli- 

 form, and at its begin- 

 ning there is a space — 

 \}i\Q. femoral ring {annulus fe moralist — between the innermost side of the femoral 

 vein, covered by a layer of fibrous tissue connecting the anterior and posterior walls 

 of the sheath, and the outer curved margin of Gimbernat's ligament (Fig. 1496). 

 This space varies in size with the degree of development of the latter structure, which, 

 as has been said, is broader and stronger in males than in females, and with the size 

 of the pectineus and ilio-psoas muscles. Its internal aspect and relations are shown 

 in Fig. 1493. The ring is on an average from 12-15 ""'ii^- (/^~f i^^- ) ^^ width in men 

 and from 18-25 nim. (^-i- in.) wide in women. The femoral canal leading down 

 from it is occupied by loose, fatty areolar tissue and some lympathic vessels. The ring 

 itself, as seen from within, presents on its surface, covered by peritoneum, a very 

 slight depression. Beneath the peritoneum at this point the extraperitoneal tissue is 

 exceptionally abundant and is frequently the site of subserous lipomata which have 

 been thought (Roser) by their traction to cause the peritoneal depression just spoken 

 of, and even to account for the development of hernia. The septum crurale {septum 

 femorale^ — variously described as a condensation of the subserous tissue and as a 

 portion of the transversalis fascia — fills in the ring and is perforated by a number of 

 lymphatic vessels passing from the inguinal to the pelvic nodes. A small lymph-node 

 not infrequently lies on the septum beneath the peritoneum. 



The bozindaries of the ring should be carefully studied in their relation to the 

 neck of a femoral hernia. On the inner side is Gimbernat's ligament, which in child- 



Poupart's 

 ligament 



Iliac fascia 



Pectineal fascia 



Aponeurosis 

 of external 

 oblique (cut) 



Vascular 

 space 



External 

 abdominal 

 ring 



Outer pillar 



Pubic spine 



Deep dissection of right half of pelvis. 



Gimbernat's ligament 

 showing attachments of iliac fascia. 



