758 



HERNIA. 



edge of the fascia lata or Hey's ligament, and 

 posteriorly by its pubic portion : both externally 

 and internally it is bounded by the junction of 

 these two portions of fascia. Gimbernat's liga- 

 ment, which is usually described as forming the 

 internal boundary of the crural ring, rarely fills 

 up more than half the space between the crest 

 of the pubis and the femoral vein. This canal, 

 as being composed of fascia, is firm, and un- 

 yielding : it cannot be influenced by the actions 

 of any muscle in the neighbourhood, nor even 

 so much as is generally supposed by the posi- 

 tion of the limb. It should follow from this 

 constitution of parts that any hernia thus re- 

 strained should forcibly compress the vein and 

 artery before it suffered strangulation itself, and' 

 so it would if the protrusion had relation to 

 this canal alone, and was not contained within 

 its own proper portion of the funnel-shaped 

 sheath already described. 



The neck of the sac of a femoral hernia, then, 

 has behind it the fascia iliaca and the ligamento- 

 cartilaginous material that covers the sharp edge 

 of the lir.ea ileo-pectinea : internally it has the 

 junction of the fascia iliaca and transversalis, 

 the attachment of the fascia lata to the liriea 

 ileo-pectinea, and Gimbernat's ligament ; inter- 

 nally it must also have the spermatic cord in 

 the male and the round ligament in the female; 

 anteriorly it has the fascia transversalis and 

 Poupart's ligament, and immediately above the 

 neck and in close contact with it is the sper- 

 matic cord, of course including the spermatic 

 artery : externally is the membranous slip in- 

 terposed between it and the femoral vein. The 

 epigastric artery is also external to it, but 

 although this vessel is somewhat irregular both 

 in origin and position, yet the full breadth of 

 the vein must be always interposed between it 

 and the neck of the sac. But there is an 

 irregular vascular distribution that must be 

 borne in mind. In a great number of subjects 

 (perhaps one out of every four or five) the 

 obturator artery, instead of coming off from the 

 internal iliac, arises by a common trunk along 

 with the epigastric, which it soon leaves, and 

 passing downwards and inwards crosses the 

 superior aperture of the femoral canal before it 

 dips into the pelvis to reach the obturator 

 foramen. In this course it sometimes passes 

 the border of the canal posteriorly, but much 

 more frequently in front; and in this latter case, 

 if a hernia existed, the vessel would embrace 

 two-thirds of the circle of the displaced peri- 

 toneum close to and immediately above the 

 neck. It appears, then, from these anatomical 

 relations that in all subjects a considerable 

 degree of danger may arise from too free and 

 unguarded a use of the knife in operation a 

 danger that is necessarily enhanced in the male 

 subject: indeed in consequence of the risk of 

 hemorrhage Scarpa seemed disposed to trust to 

 dilatation and laceration of Poupart's ligament 

 for relieving the stricture, and where these 

 means were insufficient he recommended a new 

 and particular direction to be given to the 

 incision. But from careful dissection and ex- 

 amination of these parts I am disposed to 

 believe there is always sufficient space to free a 



stricture without endangering either the sper- 

 matic or the irregular obturator artery. It must 

 be recollected that if the intestine is sufficiently 

 liberated to permit the passage of gas through 

 the immediate seat of the stricture, its return is 

 perfectly practicable, and a very small incision 

 will be sufficient to accomplish this. Now 

 these vessels lie, not on the neck of the sac, but 

 above it ; and there is quite space enough to set 

 the stricture free without interfering with them : 

 when they are wounded, it is in consequence of 

 the introduction of the cutting edge of the 

 bistoury too far within the stricture. 



When a portion of intestine has escaped 

 through the femoral ring, (and by reason of the 

 small size of the aperture herniae here are 

 seldom large,) it lies at first within the crural 

 canal, where it is restricted by the fascia lata, 

 and its existence recognized with difficulty. It 

 has happened that patients have perished from 

 the incarceration of a small fold or knuckle of 

 intestine without the circumstance ever having 

 been discovered during life. But after it has 

 passed the crescentic edge of Key's ligament, 

 and is relieved from the pressure of the fascia, 

 it comes forward, and if it increases farther, its 

 direction is rather inwards and upwards, so 

 that it may assume the position of an inguinal 

 hernia to the extent of being mistaken for it. 

 Having proceeded so far, the hernial sac has 

 assumed somewhat of the form of an arch : it 

 has passed, first downwards through the 

 femoral canal, then forwards under the sharp 

 edge of the fascia lata, either passing through 

 the weak cellular portion of it or pushing it 

 before, and then upwards and inwards in front. 

 The hollow of this arch looks upwards, and is 

 occupied by the crescentic edge of Hey's liga- 

 ment. Perhaps this particular position of the 

 hernia, as well as the extreme straitness and un- 

 yielding nature of the crural canal, has con- 

 tributed to the frequency of strangulation to 

 which this form of hernia is liable. 



When a person stands erect and without 

 exertion, Poupart's ligament forms nearly a 

 direct line between the anterior superior spinous 

 process of the ileum and the crest of the pubis, 

 and all the fasciee connected to it are in their 

 natural state and sufficiently relaxed ; but if the 

 thigh is strongly extended or the body bent 

 backward, the ligament then becomes tense and 

 is arched backward toward the thigh. The 

 effect of the general tension of the limb in this 

 position would be to convert the arch formed 

 by the hernia into an angle, against the hollow 

 of which the edge of Hey's ligament would be 

 firmly compressed, and a sufficient degree of 

 resistance thus created to the return of the 

 venous blood to produce a congested condition 

 of the viscus. The operation of such a cause 

 as this can hardly be considered as permanent, 

 but the mischief once commenced is not easily 

 controlled, and an intestine might soon be 

 placed in such a condition as to render incar- 

 ceration at the ring inevitable. 



The situations at which crural hernia may 

 be strangulated have not been satisfactorily 

 described, although there is no subject on which 

 more anatomical labour has been bestowed. If 



