HERNIA. 



759 



I was to speak from my own experience alone, 

 I should say that though the hernia itself is 

 superficial, the seat of the strangulation is 

 always deep somewhere at or in the imme- 

 diate neighbourhood of the neck of the sac. I 

 found the opinion partly on the dissection of 

 subjects that had died of the disease, but more 

 particularly on the phenomena I have observed 

 during the progress of an operation on the 

 living: still the experience of one individual 

 can scarcely ever be sufficient to establish a 

 great pathological principle, and there is autho- 

 rity that cannot be questioned for believing 

 that crural hernia is frequently strictured at a 

 far less depth from the surface. Besides the 

 neck of the sac, by which this hernia is con- 

 fessedly strictured in very many cases, Sir A. 

 Cooper places the seat of strangulation, first in 

 the crural sheath and semilunar or lunated 

 edge of the fascia lata, and secondly in the 

 posterior edge of the fascia lata.* Mr. Colles 

 says that the neck or constricted part of crural 

 hernia does not always appear at the same 

 depth from the surface, and explains the cir- 

 cumstance thus : "The hernia having descended 

 into the femoral sheath, it escapes through one 

 of those apertures in it for transmitting the 

 lymphatic vessels, and also passes through a 

 corresponding opening in the iliac portion of 

 the fascia lata. As it passes through a small 

 aperture in each of these parts at nearly the 

 same spot, it must there be liable to great con- 

 striction ; for these two layers of fascia will be 

 compressed together, and thus their strength 

 and resistance be considerably augmented. 

 Hence we should find the seat of stricture in 

 strangulated femoral hernia frequently to be at 

 some distance below and to the pubic side of 

 the crural ring."f The descriptions of Hey and 

 Burns I cannot profess clearly to understand, 

 and I fear they were taken rather from sound 

 subjects than from those in which hernia? were 

 actually present. Scarpa does not distinctly 

 point out the anatomy of the seat of stricture, 

 but from the general bearing of his descriptions, 

 and above all from the anxiety he expresses 

 relative to the danger of wounding the sper- 

 matic artery in operation, which vessel, if pre- 

 sent, must lie close to the neck of the sac, I 

 would hazard an opinion that he believed the 

 seat of strangulation to be always deeply 

 seated. 



In dissecting this rupture from without, or 

 in operating upon it in the living, it will be 

 found to He at a different depth from the sur- 

 face, and to possess variety in the number of 

 fascial coverings according to its position with 

 reference to the parts already described. Thus 

 it may be placed within the crural canal, 

 within that triangular space formed by the 

 fascia lata ; or having passed beyond its inferior 

 opening or falciform edge, it may present 

 more superficially. In the former case, after 

 the division of the common integuments, the 

 skin and fat, the superficial fascia is exposed 

 and may consist of many layers at all events 



* Cooper on Hernia, part ii p. 1 1. 

 t Colics' Surgical Anatomy, \>. 77. 



of two : next is the dense and resisting fascia 

 lata of the thigh ; and deeper still, the funnel- 

 shaped fascia in which the crural ring is situated. 

 Between this latter and the sac another fascia 

 has been described under the name of the fascia 

 propria, which may be supposed to be formed 

 by a condensation of that cellular tissue already 

 described as occupying the crural ring; but I 

 have never been able to satisfy myself as to the 

 existence of this as a distinct membrane, and I 

 must again caution the young operator not to 

 expect to meet with laminae of fascia as de- 

 scribed or demonstrated by the anatomist. A 

 dexterous and careful dissector may make al- 

 most as many layers of fascia as he pleases. 



After it has passed the inferior border of the 

 crural canal and appeared more externally, the 

 coverings of fascia to be expected must depend 

 on the view taken of the anatomy of this part. 

 If it is believed that the hernia having cleared 

 this point merely swells out on being relieved 

 from the pressure, without passing or pushing 

 through any of the superincumbent structures, 

 then in order to come down upon the sac it 

 would be necessary to divide the skin and 

 cellular tissue, the different laminae of the fascia 

 superficialis, the cribriform portion of the fascia 

 lata, the anterior portion of the funnel-shaped 

 fascia, and the fascia propria. If, on the other 

 hand, it is supposed that the hernia has escaped 

 through one of the openings in the femoral 

 sheath, and a corresponding one in the iliac 

 portion of the fascia lata, it will lie more super- 

 ficial by the absence of these investments. In 

 either case the last layer of fascia most adja- 

 cent to the sac is almost always remarkable for 

 density and strength. 



The general symptoms of this affection are 

 the same with those of inguinal, such as the 

 appearance of the tumour, its diminution or 

 disappearance in the recumbent position, and 

 the impulse imparted to it by coughing, sneez- 

 ing, &c. : its peculiar symptoms are explicable 

 by its anatomical relations. 1. The crural 

 hernia is generally small and its increase slow : 

 the size of the ring and the compression ex- 

 ercised on it by so many superincumbent 

 layers of fascia will be sufficient to account for 

 this, and also will shew why this rupture is 

 almost always painful, and why position has so 

 much effect on it, relief being constantly ob- 

 tained by bending the thigh on the pelvis and 

 rotating the limb inwards. 2. The peculiar 

 manner of growth, its first passing downwards, 

 then forwards, and then upwards and inwards, 

 is caused by the attachment of the funnel-like 

 fascia to the vessels at the superior part of the 

 thigh, and by that of the fascia superficial 

 to the fascia lata near the entrance of the 

 saphena vein ; thus its shape is never pyramidal 

 like that of inguinal ; it is globular or oval, and 

 its longest diameter is transverse. 3. I have- 

 already mentioned its prevalence amongst 

 females advanced in life. 



As the testicle is more subject to disease 

 than any structure at the top of the thigh, there 

 are more affections with which scrotal hernia 

 may be confounded; but on the other hand, 

 when a doubt arises on the subject of crural 



