1402 CLINICAL AND TOPOGRAPHICAL ANATOMY 



every five cases the obturator arises from the inferior epigastric. In about thirty-seven per 

 cent, of the cases with such an origin the artery either crosses or courses along the side of the 

 ring. (Cunningham.) 



Course of femoral hernia. — ^At first this is downward in the femoral canal. A pouch of 

 peritoneum having been gradually, after repeated straining, coughing, etc., pushed thi-ough the 

 weak spot, the femoral ring, further weakened perhaps, together with all the parts in the fem- 

 oral arch, by child-bearing, some extra effort will force intestine or omentum into this pouch and 

 thus form a hernia. Thus formed, femoral hernia passes at first downward in the femoral canal 

 as far as the fossa ovalis, but, as a rule, does not go farther downward on the thigh, but mounts 

 forward and upward, and somewhat laterally, even reaching the level of the inguinal ligament. 

 The reasons for this change of position are: — (1) The narrowing of the femoral sheath, funnel- 

 like, i. e.. wide above, but narrowed below; (2) the unyielding nature of the lower margin of the 

 fossa ovalis; (3) the fact that this margin and the lateral border are united to the femoral sheath; 

 (4) the constant flexion of the thigh; (5) the fact that vessels (claiefly veins) and lymphatics 

 descend to the fossa ovalis, the veins to join the saphenous vein and the lymphatics to join 

 the deeper group; these descending vessels serve to loop upward or suspend a femoral hernia, 

 and thus prevent its fm-ther course downward. 



Coverings of a femoral hernia. — (A) At the upper or femoral ring it obtains 

 peritoneum, extra-peritoneal fat, and septum femorale (crurale). 



(B) In the canal, a coating of the femoral sheath, 



(C) At the external opening, further coverings of cribriform fascia, skin, 

 and superficial fascia are added. 



Some of these may be deficient by the hernia bursting through them, or they may be matted 

 together. Sir A. Cooper thought this especially likely to occur with the layer of femoral sheath 

 and septum crm-ale, to which he gave the name oi fascia propria. 



The relations of an inguinal and femoral hernia respectively to the pubic tubercle are of 

 importance in distinguishing between them clinically. If a finger is placed on the pubic tubercle 

 a hernia that lies above and medial to it will be inguinal, one below and lateral to it will be 

 femoral. 



Radical cure of femoral hernia. — The close proximity of the femoral vein always intro- 

 duces difficulty in the introduction of the deep sutures for closure of the crural ring. Any clo- 

 sure below this point is certain to be inefficient. The safest and simplest method is to feel 

 for the pulsation of the femoral artery, and make allowance for the vein on its medial side. The 

 latter vessel is then protected by the finger-tip passed up the femoral canal, so that its dorsum 

 rests against the vein and its tip upon the linea terminalis. The sutures are then passed so 

 as to pick up the ilio-pectineal fascia and its thickened part. Cooper's ligament, below, and the 

 deep crural arch and Poupart's ligament above (fig. 1122). Thus, when tightened, they draw 

 the anterior and posterior boundaries of the ring together. (Lockwood, Bassini.) 



PARTS CONCERNED IN UMBILICAL HERNIA 



A hernial protrusion at the umbilicus, or exomphalos, may occur at three 

 distinct periods of life, according to the anatomy of the part. Any account of 

 umbilical hernia would be incomplete without an attempt to explain how this 

 region, originally a most distinct opening, is gradually closed and changed into 

 a knotty mass of scar, the strongest point in the abdominal wall. 



During the first weeks of foetal life, in addition to the urachus, umbilical 

 arteries, and vein, some of the mesentery and a loop of the intestine pass through 

 the opening to occupy a portion of the body cavity situated in the umbilical cord, 

 later on returning to the abdominal cavity. Occasionally this condition persists, 

 owing to failure of development, and the child is born with a large hernial swell- 

 ing outside the abdomen, imperfectly covered with skin and peritoneum. To 

 this condition the term congenital umbilical hernia should be applied. 



Later on in foetal life it is the umbilical vessels alone which pass through this 

 opening. At Inrth there is a distinct ring, which can be felt for some time after 

 in the flaccid walls of an infant's belly. If this condition persist, a piece of 

 intestine may find its way through, forming the condition which should be known 

 as infantile umbilical hernia. 



This condition is not uncommon. Why it is not more frequently met with 

 is explained by the way in which this ring of infancy is closed and gradually 

 converted into the den.se mass of scar tissue so familiar in adult life. This is 

 brought about — (1) l)y changes in the ring itself; (2) by changes in the vessels 

 which pass through it. 



(1) Changes in the ring itself. — The umbilical ring is surrounded by a sphincter-like 

 arrangement of elastic fibres, best seen during the first few days of extra-uterine life, on the 



