which the cord (and consequently the oblique hernia) bears to the lower
margins of the oblique and transverse muscles, and their cremasteric
prolongation. Mr. Guthrie (Inguinal and Femoral Hernia) has shown that
the fibres of the transversalis, as well as those of the internal
oblique, are penetrated by the cord. Albinus, Haller, Cloquet, Camper,
and Scarpa, record opinions from which it may be gathered that this
disposition of the parts is (with some exceptions) general. Sir Astley
Cooper describes the lower edge of the transversalis as curved all round
the internal ring and cord. From my own observations, coupled with
these, I am inclined to the belief that, instead of viewing these facts
as isolated and meaningless particulars, we should now fuse them into
the one idea expressed by the philosophic Carus, and adopted by Cloquet,
that the cremaster is a production of the abdominal muscles, formed
mechanically by the testicle, which in its descent dilates, penetrates,
and elongates their fibres.]
[Illustration: Abdomen, showing bone, blood vessels
and other internal organs.]
Plate 41--Figure 6
PLATE 41. Fig. 7.--When an external inguinal hernia, 11, dilates and
protrudes the peritonaeum from the closed internal ring, 1, and descends
the inguinal canal and fibrous tube, 3, 3, it imitates, in most
respects, the original descent of the testicle. The difference between
both descents attaches alone to the mode in which they become covered by
the serous membrane; for the testicle passes through the internal ring
behind the inguinal peritonaeum, at the same time that it takes a
duplicature of this membrane; whereas the bowel encounters this part of
the peritonaeum from within, and in this mode becomes invested by it on
all sides. This figure also represents the form and relative position of
a hernia, as occurring in Figs. 1 and 3, 5, and 6, Plate 41.
[Illustration: Abdomen, showing bone, blood vessels
and other internal organs.]
Plate 41--Figure 7
PLATE 41, Fig. 8.--When the serous spermatic tube only closes at the
internal ring, as seen at 1, Fig. 4, Plate 41, if a hernia afterwards
pouch the peritonaeum at this part, and enter the inguinal canal, we
shall then have the form of hernia, Fig. 8, Plate 41, termed infantile.
Two serous sacs will be here found, one within the cord, 13, and
communicating with the tunica vaginalis, the other, 11, containing the
bowel, and being received by inversion into the upper extremity of the
first. Thus the infantile serous canal, 13, receives the hernial sac,
11. The inguinal canal and cord may become multicapsular, as in Fig. 8,
from various causes, each capsule being a distinct serous membrane.
First, independent of hernial formation, the original serous tube may
become interruptedly obliterated, as in Plate 40, Fig. 2. Secondly,
these sacs may persist to adult age, and have a hernial sac added to
their number, whatever this may be. Thirdly, the original serous tube,
13, Fig. 8, may persist, and after having received the hernial sac, 11,
the bowel may have been reduced, leaving its sac behind it in the
inguinal canal; the neck of this sac may have been obliterated by the
pressure of a truss, a second hernia may protrude at the point 1, and
this may be received into the first hernial sac in the same manner as
the first was received into the original serous infantile tube. The
possibility of these occurrences is self-evident, even if they were
never as yet experienced. [Footnote]
[Footnote: According to Mr. Lawrence and M. Cloquet, most of the serous
cysts found around hernial tumours are ancient sacs obliterated at the
neck, and adhering to the new swelling (opera cit.)]
[Illustration: Abdomen, showing bone, blood vessels
and other internal organs.]
Plate 41--Figure 8
PLATE 42, Fig. 1.--The epigastric artery, 9, being covered by the fascia
transversalis, can lend no support to the internal ring, 2, 2, nor to
the tube prolonged from it. The herniary bowel may, therefore, dilate
the peritonaeum immediately on the inner side of the artery, and enter
the inguinal canal. In this way the hernia, 11, although situated
internal to the epigastric artery, assumes an oblique course through the
canal, and thus closely simulates the external variety of inguinal
hernia, Fig. 7, Plate 41. If the hernia enter the canal, as represented
in Fig. 1, Plate 42, it becomes invested by the same structures, and
assumes the same position in respect to the spermatic vessels, as the
external hernia.
[Illustration: Abdomen and scrotum, showing bone, blood vessels
and other internal organs.]
Plate 42--Figure 1
PLATE 42, Fig. 2.--The hernial sac, 11, which entered the ring of the
fibrous tube, 2, 2, at a point immediately internal to the epigastric
artery, 9, may, from having been at first oblique, as in Fig. 1, Plate
42, assume a direct position. In this case, the ring of the fibrous
tube, 2, 2, will be much widened; but the artery and spermatic vessels
will remain in their normal position, being in no wise affected by the
gravitating hernia. If the conjoined tendon, 6, be so weak as not to
resist the gravitating force of the hernia, the tendon will become bent
upon itself. If the umbilical cord, 10, be side by side with the
epigastric artery at the time that the hernia enters the mouth of the
fibrous tube, then, of course, the cord will be found external. If the
cord lie towards the pubes, apart from the vessel, the hernia may enter
the fibrous tube between the cord, 10, and artery, 9. [Footnote:] It is
impossible for any internal hernia to assume the congenital form,
because the neck of the original serous spermatic tube, 11, Fig. 2,
Plate 41, being external to the epigastric artery, 9, cannot be entered
by the hernia, which originates internally to this vessel.
[Footnote: M. Cloquet states that the umbilical cord is always found on
the inner side of the external hernia. Its position varies in respect to
the internal hernia, (op. cit. prop. 52.)]
[Illustration: Abdomen and scrotum, showing bone, blood vessels
and other internal organs.]
Plate 42--Figure 2
PLATE 42, Fig. 3.--Every internal hernia, which does not rupture the
peritonaeum, carries forward a sac produced anew from this membrane,
whether the hernia enter the inguinal canal or not. But this is not the
case with respect to the fibrous membrane which forms the fascia
propria. If the hernia enter the inguinal wall immediately on the inner
side of the epigastric artery, Fig. 1, Plate 42, it passes direct into
the ring of the fibrous tube, 2, 2, already prepared to receive it. But
when the hernia, 11, Fig. 3, Plate 42, cleaves the conjoined tendon, 6,
6, then the artery, 9, and the tube, 2, 2, remain in their usual
position, while the bowel carries forward a new investment from the
transversalis fascia, 5, 5. That part of the conjoined tendon which
stands external to the hernia keeps the tube, 2, 2, in its proper place,
and separates it from the fold of the fascia which invests the hernial
sac. This is the only form in which an internal hernia can be said to be
absolutely distinct from the inguinal canal and spermatic vessels. This
hernia, when passing the external ring, 4, has the spermatic cord on its
outer side.
[Illustration: Abdomen and scrotum, showing bone, blood vessels
and other internal organs.]
Plate 42--Figure 3
PLATE 42, Fig. 4.--The external hernia, from having been originally
oblique, may assume the position of a hernia originally internal and
direct. The change of place exhibited by this form of hernia does not
imply a change either in its original investments or in its position
with respect to the epigastric artery and spermatic vessels. The change
is merely caused by the weight and gravitation of the hernial mass,
which bends the epigastric artery, 9*, from its first position on the
inner margin of the internal ring, 1, till it assumes the place 9. In
consequence of this, the internal ring of the fascia transversalis, 2,
2, is considerably widened, as it is also in Fig. 2, Plate 42. It is the
inner margin of the fibrous ring which has suffered the pressure; and
thus the hernia now projects directly from behind forwards, through, 4,
the external ring. The conjoined tendon, 6, when weak, becomes bent upon
itself. The change of place performed by the gravitating hernia may
disturb the order and relative position of the spermatic vessels; but
these, as well as the hernia, still occupy the inguinal canal, and are
invested by the spermatic fascia, 3, 3. When an internal hernia, Fig. 1,
Plate 42, enters the inguinal canal, it also may descend the cord as far
as the testicle, and assume in respect to this gland the same position
as the external hernia. [Footnote]
[Footnote: As the external hernia, Fig. 4, Plate 42, may displace the
epigastric artery inwards, so may the internal hernia, Fig. 1, Plate 42,
displace the artery outwards. Mr. Lawrence, Sir Astley Cooper, Scarpa,
Hesselbach, and Langenbeck, state, however, that the internal hernia
does not disturb the artery from its usual position three-fourths of an
inch from the external ring.]
[Illustration: Abdomen and scrotum, showing bone, blood vessels
and other internal organs.]
Plate 42--Figure 4
PLATE 42, Figs. 5, 6, 7.--The form and position of the inguinal canal
varies according to the sex and age of the individual. In early life,
Fig. 6, the internal ring is situated nearly opposite to the external
ring, 4. As the pelvis widens gradually in the advance to adult age,
Fig. 5, the canal becomes oblique as to position. This obliquity is
caused by a change of place, performed rather by the internal than the
external ring. [Footnote] The greater width of the female pelvis than of
the male, renders the canal more oblique in the former; and this,
combined with the circumstance that the female inguinal canal, Fig. 7,
merely transmits the round ligament, 14, accounts anatomically for the
fact, that this sex is less liable to the occurrence of rupture in this
situation.
[Footnote: M. Velpeau (Nouveaux Elemens de med. Operat.) states the
length of the inguinal canal in a well-formed adult, measured from the
internal to the external ring, to be 1-1/2 or 2 inches, and 3 inches
including the rings; but that in some individuals the rings are placed
nearly opposite; whilst in young subjects the two rings nearly always
correspond. When, in company with these facts, we recollect how much the
parts are liable to be disturbed in ruptures, it must be evident that
their relative position cannot be exactly ascertained by measurement,
from any given point whatever. The judgment alone must fix the general
average.]
[Illustration: Abdomen and scrotum, showing bone, blood vessels
and other internal organs.]
Plate 42--Figure 5
[Illustration: Abdomen and scrotum, showing bone, blood vessels
and other internal organs.]
Plate 42--Figure 6
[Illustration: Abdomen, showing bone, blood vessels
and other internal organs.]
Plate 42--Figure 7
COMMENTARY ON PLATES 43 & 44.
THE DISSECTION OF FEMORAL HERNIA, AND THE SEAT OF STRICTURE.
Whilst all forms of inguinal herniae escape from the abdomen at places
situated immediately above Poupart's ligament, the femoral hernia, G,
Fig. 1, Plate 43, is found to pass from the abdomen immediately below
this structure, A I, and between it and the horizontal branch of the
pubic bone. The inguinal canal and external abdominal ring are parts
concerned in the passage of inguinal herniae, whether oblique or direct,
external or internal; whilst the femoral canal and saphenous opening are
the parts through which the femoral hernia passes. Both these orders of
parts, and of the herniae connected with them respectively, are,
however, in reality situated so closely to each other in the
inguino-femoral region, that, in order to understand either, we should,
examine both at the same time comparatively.
The structure which is named Poupart's ligament in connexion with
inguinal herniae, is named the femoral or crural arch (Gimbernat) in
relation to femoral hernia. The simple line, therefore, described by
this ligament explains the narrow interval which separates both
varieties of the complaint. So small is the line of separation described
between these herniae by the ligament, that this (so to express the
idea) stands in the character of an arch, which, at the same time,
supports an aqueduct (the inguinal canal) and spans a road (the femoral
sheath.) The femoral arch, A I, Fig. 1, Plate 43, extends between the
anterior superior iliac spinous process and the pubic spine. It connects
the aponeurosis of the external oblique muscle, D d, Fig. 2, Plate 44,
with F, the fascia lata. Immediately above and below its pubic extremity
appear the external ring and the saphenous opening. On cutting through
the falciform process, F, Fig. 1, Plate 44, we find Gimbernat's
ligament, R, a structure well known in connexion with femoral hernia.
Gimbernat's ligament consists of tendinous fibres which connect the
inner end of the femoral arch with the pectineal ridge of the os pubis.
The shape of the ligament is acutely triangular, corresponding to the
form of the space which it occupies. Its apex is internal, and close to
the pubic spine; its base is external, sharp and concave, and in
apposition with the sheath of the femoral vessels. It measures an inch,
more or less, in width, and it is broader in the male than in the
female--a fact which is said to account for the greater frequency of
femoral hernia in the latter sex than in the former, (Monro.) Its
strength and density also vary in different individuals. It is covered
anteriorly by, P, Fig. 1, Plate 44, the upper cornu of the falciform
process; and behind, it is in connexion with, k, the conjoined tendon.
This tendon is inserted with the ligament into the pectineal ridge. The
falciform process also blends with the ligament; and thus it is that the
femoral hernia, when constricted by either of these three structures,
may well be supposed to suffer pressure from the three together.
A second or deep femoral arch is occasionally met with. This structure
consists of tendinous fibres, lying deeper than, but parallel with,
those of the superficial arch. The deep arch spans the femoral sheath
more closely than the superficial arch, and occupies the interval left
between the latter and the sheath of the vessels. When the deep arch
exists, its inner end blends with the conjoined tendon and Gimbernat's
ligament, and with these may also constrict the femoral hernia.
The sheath, e f, of the femoral vessels, E F, Fig. 1, Plate 43, passes
from beneath the middle of the femoral arch. In this situation, the
iliac part of the fascia lata, F G, Fig. 2, Plate 44, covers the sheath.
Its inner side is bounded by Gimbernat's ligament, R, Fig. 1, Plate 44,
and F, the falciform edge of the saphenous opening. On its outer side
are situated the anterior crural nerve, and the femoral parts of the
psoas and iliacus muscles. Of the three compartments into which the
sheath is divided by two septa in its interior, the external one, E,
Fig. 1, Plate 43, is occupied by the femoral artery; the middle one, F,
by the femoral vein; whilst the inner one, G, gives passage to the
femoral lymphatic vessels; and occasionally, also, a lymphatic body is
found in it. The inner compartment, G, is the femoral canal, and through
it the femoral hernia descends from the abdomen to the upper and
forepart of the thigh. As the canal is the innermost of the three spaces
inclosed by the sheath, it is that which lies in the immediate
neighbourhood of the saphenous opening, Gimbernat's ligament, and the
conjoined tendon, and between these structures and the femoral vein.
The sheath of the femoral vessels, like that of the spermatic cord, is
infundibuliform. Both are broader at their abdominal ends than
elsewhere. The femoral sheath being broader above than below, whilst the
vessels are of a uniform diameter, presents, as it were, a surplus space
to receive a hernia into its upper end. This space is the femoral or
crural canal. Its abdominal entrance is the femoral or crural ring.
The femoral ring, H, Fig. 2, Plate 43, is, in the natural state of the
parts, closed over by the peritonaeum, in the same manner as this
membrane shuts the internal inguinal ring. There is, however,
corresponding to each ring, a depression in the peritonaeal covering;
and here it is that the bowel first forces the membrane and forms of
this part its sac.
On removing the peritonaeum from the inguinal wall on the inner side of
the iliac vessels, K L, we find the horizontal branch of the os pubis,
and the parts connected with it above and below, to be still covered by
what is called the subserous tissue. The femoral ring is not as yet
discernible on the inner side of the iliac vein, K; for the subserous
tissue being stretched across this aperture masks it. The portion of the
tissue which closes the ring is named the crural septum, (Cloquet.) When
we remove this part, we open the femoral ring leading to the
corresponding canal. The ring is the point of union between the fibrous
membrane of the canal and the general fibrous membrane which lines the
abdominal walls external to the peritonaeum. This account of the
continuity between the canal and abdominal fibrous membrane equally
applies to the connexion existing between the general sheath of the
vessels and the abdominal membrane. The difference exists in the fact,
that the two outer compartments of the sheath are occupied by the
vessels, whilst the inner one is vacant. The neck or inlet of the
hernial sac, H, Fig. 2, Plate 43, exactly represents the natural form of
the crural ring, as formed in the fibrous membrane external to, or (as
seen in this view) beneath the peritonaeum.
The femoral ring, H, is girt round on all sides by a dense fibrous
circle, the upper arc being formed by the two femoral arches; the outer
arc is represented by the septum of the femoral sheath, which separates
the femoral vein from the canal; the inner arc is formed by the united
dense fibrous bands of the conjoined tendon and Gimbernat's ligament;
and the inferior arc is formed by the pelvic fascia where this passes
over the pubic bone to unite with the under part of the femoral canal
and sheath. The ring thus bound by dense resisting fibrous structure, is
rendered sharp on its pubic and upper sides by the salient edges of the
conjoined tendon and Gimbernat's ligament, &c. From the femoral ring the
canal extends down the thigh for an inch and a-half or two inches in a
tapering form, supported by the pectineus muscle, and covered by the
iliac part of the fascia lata. It lies side by side with the saphenous
opening, but does not communicate with this place. On a level with the
lower cornu of the saphenous opening, the walls of the canal become
closely applied to the femoral vessels, and here it may be said to
terminate.
The bloodvessels which pass in the neighbourhood of the femoral canal
are, 1st. the femoral vein, F, Fig. 1, Plate 43, which enclosed in its
proper sheath lies parallel with and close to the outer side of the
passage. 2nd, Within the inguinal canal above are the spermatic vessels,
resting on the upper surface of the femoral arch, which alone separates
them from the upper part or entrance of the femoral canal. 3rd, The
epigastric artery, F, Fig. 2, Plate 43, which passes close to the outer
and upper border of, H, the femoral ring. This vessel occasionally gives
off the obturator artery, which, when thus derived, will be found to
pass towards the obturator foramen, in close connexion with the ring;
that is, either descending by its outer border, G*, between this point
and the iliac vein, K; or arching the ring, G, so as to pass down close
to its inner or pubic border. In some instances, the vessel crosses the
ring; a vein generally accompanies the artery. These peculiarities in
the origin and course of the obturator artery, especially that of
passing on the pubic side of the ring, behind Gimbernat's ligament and
the conjoined tendon, E H, are fortunately very rare.
As the course to be taken by the bowel, when a femoral hernia is being
formed, is through the crural ring and canal, the structures which have
just now been enumerated as bounding this passage, will, of course, hold
the like relation to the hernia. The manner in which a femoral hernia is
formed, and the way in which it becomes invested in its descent, may be
briefly stated thus: The bowel first dilates the peritonaeum opposite
the femoral ring, H, Fig. 2, Plate 43, and pushes this membrane before
it into the canal. This covering is the hernial sac. The crural septum
has, at the same time, entered the canal as a second investment of the
bowel. The hernia is now enclosed by the sheath, G, Fig. 1, Plate 43, of
the canal itself. [Footnote 1] Its further progress through the
saphenous opening, B F, Fig. 1, Plate 44, must be made either by
rupturing the weak inner wall of the canal, or by dilating this part; in
one or other of these modes, the herniary sac emerges from the canal
through the saphenous opening. In general, it dilates the side of the
canal, and this becomes the fascia propria, B G. If it have ruptured the
canal, the hernial sac appears devoid of this covering. In either case,
the hernia, increasing in size, turns up over the margin of F, the
falciform process, [Footnote 2] and ultimately rests upon the iliac
fascia lata, below the pubic third of Poupart's ligament. Sometimes the
hernia rests upon this ligament, and simulates, to all outward
appearance, an oblique inguinal hernia. In this course, the femoral
hernia will have its three parts--neck, body, and fundus--forming nearly
right angles with each other: its neck [Footnote 3] descends the crural
canal, its body is directed to the pubis through the saphenous opening,
and its fundus is turned upwards to the femoral arch.
[Footnote 1: The sheath of the canal, together with the crural septum,
constitutes the "fascia propria" of the hernia (Sir Astley Cooper). Mr.
Lawrence denies the existence of the crural septum.]
[Footnote 2: The "upper cornu of the saphenous opening," the "falciform
process" (Burns), and the "femoral ligament" (Hey), are names applied to
the same part. With what difficulty and perplexity does this
impenetrable fog of surgical nomenclature beset the progress of the
learner!]
[Footnote 3: The neck of the sac at the femoral ring lies very deep, in
the undissected state of the parts (Lawrence).]
The crural hernia is much more liable to suffer constriction than the
inguinal hernia. The peculiar sinuous course which the former takes from
its point of origin, at the crural ring, to its place on Poupart's
ligament, and the unyielding fibrous structures which form the canal
through which it passes, fully account for the more frequent occurrence
of this casualty. The neck of the sac may, indeed, be supposed always to
suffer more or less constriction at the crural ring. The part which
occupies the canal is also very much compressed; and again, where the
hernia turns over the falciform process, this structure likewise must
cause considerable compression on the bowel in the sac. [Footnote] This
hernia suffers stricture of the passive kind always; for the dense
fibrous bands in its neighbourhood compress it rather by withstanding
the force of the herniary mass than by reacting upon it. There are no
muscular fibres crossing the course of this hernia; neither are the
parts which constrict it likely to change their original position,
however long it may exist. In the inguinal hernia, the weight of the
mass may in process of time widen the canal by gravitating; but the
crural hernia, resting on the pubic bone, cannot be supposed to dilate
the crural ring, however greatly the protrusion may increase in size and
weight.
[Footnote: Sir A. Cooper (Crural Hernia) is of opinion that the
stricture is generally in the neck of the sheath. Mr. Lawrence remarks,
"My own observations of the subject have led me to refer the cause of
stricture to the thin posterior border (Gimbernat's ligament) of the
crural arch, at the part where it is connected to the falciform
process." (Op. cit.) This statement agrees also with the experience of
Hey, (Practical Obs.)]
DESCRIPTION OF THE FIGURES OF PLATES 43 & 44.
PLATE 43.
FIGURE 1.
A. Anterior superior iliac spine.
B. Iliacus muscle, cut.
C. Anterior crural nerve, cut.
D. Psoas muscle, cut.
E. Femoral artery enclosed in e, its compartment of the femoral sheath.