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Anatomy of Femoral Hernia.

BY F. BYRON BOBINSON, Professor of Gynecology in Post-Graduate School, CHICAGO, ILL.

General, accurate anatomical knowledge of femoral hernia can scarcely be expected from present methods of medical instruction. Two things are absolutely necessary for exact anatomical and surgical knowledge of femoral hernia. 1. One must have opportunity to use dissecting material. 2. Repeated personal dissections of the parts are requisite for an understanding of the conditions on which it is based and cured. A third condition might be named, and that is clinical observation of cases.

Anatomy learned from a book only is always exaggerated or deficient, not to say nearly always incorrect. The description of the parts of femoral hernia are generally so complicated that the student frequently abandons the subject long betore his knowledge is even practical, not to speak of accuracy.

One way to simplify the description of the parts in femoral hernia is to consider the femoral canal alone, and then consider the independent coverings separate. The femoral canal has two ends, an in

No. 3.

ternal one covered by a layer of connective tissue, which should be called the femoral septum. The external end of the canal is covered by a layer of the deep superficial fascia. Because this fascia is perforated by canals for the passage of vessels it is called the cribriform fascia. It would be better to simply say that the lower end of the canal was not open at all-its lower end is closed just as the lower end of a grain sac is closed. In this way the cribriform, or deep superficial, would belong to the independent coverings of femoral hernia. The femoral canal itself is a part of the femoral sheath. The femoral sheath is formed by the iliac fascia descending behind the ilia vein and artery, while the transversalis fascia descends in front of these vessels. The fascia unite on their external edge just outside of the femoral artery, and on their internal edge just internal to the femoral vein, and sheath and vessels pass under Poupart's ligament.

This femoral sheath, composed posteriorly of the iliac fascia, and anteriorly of transversalis fascia and containing the artery and vein, is divided into compartments-three compartments, one for the artery, one for the vein, and one for the femoral canal. If one will imagine a

grain sac entirely open at its upper mouth, and open for two-thirds of its lower end and divided into three distinct sheaths by two seams from top to bottom, he will have a fair idea of the femoral sheath. The one-third of the bottom of the sac closed would represent the femoral canal, while the two other open sheaths would represent passages for the artery and vein. The femoral canal is that part of the femoral sheath which projects internal to the femoral vein. The femoral canal is the most internal division of the femoral sheath. A septum of tissue divides the artery from the vein, and, also, one divides the vein from the femoral canal.

The external edges of the iliac fascia and the transversalis fascia meet snugly against the artery, but these fascia do Let meet internally snugly against the femoral vein. A space is left between the vein and external edge of Gimbernat's ligament. This space is occupied by the femoral canal.

The femoral canal is not an open passage normally; it is only an open canal by force or congenital conditions. It is what is known as a potential canal.

The femoral canal is a useless relic which, like all relics of animal life, is dangerous. It forms a compromising space between Gimbernat's ligament and the femoral vein. The only utility which can be attributed to the femoral canal is that it does not allow the femoral vein to be compressed. The canal furnishes an elastic, yielding bed for the sluggish, variable, venous current to play on.

The femoral canal is larger in women than in men. So far as I can study dissections, it seems to me that the femoral canal is larger in women than men for two reasons. 1. Gimbernat's ligament is not so broad in women. A larger space is left between the edge of the ligament and the internal edge of the femoral vein. Gimbernat's ligament is broader in men than women according to my dissections. Gimbernat's ligament approaches closer to and surrounds the vein more in men than it does in women, i. e., it extends further towards the iliac region under Poupart's ligament and on the ileo-pectineal line in men than in women. 2. The distance between the anterior superior spine of the ilium and the pubic spine is

relatively greater in women than men. This condition renders a more yielding Poupart's ligament and a more yielding femoral sheath, giving more chance under pressure for viscera to dilate the femoral canal.

All hernial canals must be looked on as weak points in the abdominal wall.

The femoral canal is probably one-half inch wide and less in length. Its internal mouth is covered by the femoral septum, and on that lies some areolar tissue. The obturator artery is very irregular in its course, and when it arises from the deep epigastric it may absolutely surround the internal mouth of the femoral canal. I have seen this artery skirt around the edge of the internal femoral ring in various manners at least five times in about sixty carefully dissected bodies.

I wish to record here a curious anomaly in regard to hernia. In a female subject on the left side the obturator and deep epigastric artery arose as one common trunk from the external iliac two inches above Poupart's ligament. The common trunk was about two inches long, and the obturator then proceeded towards the obturator foramen in such a way as to surround about half of the femoral ring on its pubic aspect, while a small branch from the deep epigastric skirted the border of the ring on the portion surrounded by Gimbernat's and Poupart's ligaments. Thus, the femoral ring was almost entirely surrounded at its internal mouth by a large and small artery (obturator and epigastric).

In operating on such a case as this where the large obturator artery lies snugly against the pubic bone and border of Gimbernat's ligament, great danger would arise from wounding the artery. However, the artery in all such cases is not fixed, and a dull instrument would push it away. I found the right side of this subject normal, i. e., the obturator rose from near the base of the deep epigastric.

In cutting Gimbernat's ligament to relieve hernia in such cases there is much danger of severing the artery. In any case the only safe point to attack Gimbernat's ligament is at the point where it is attached to the ileo-pectineal line. It should then be done with a blunt in

strument. The artery is not fixed and would glide away from a dull instru. ment. The bowel will glide back with a very slight amount of tearing of Gimbernat's ligament.

In the femoral canal we then have its internal mouth closed by the femoral septum, and its lower or external mouth is closed by the femoral sheath, i. e., its bottom was never open like it is in inguinal hernia. The canal is occupied by mainly lymphatics. If one introduces the finger between the femoral vein and the edge of Gimbernat's ligament, it is quickly perceived that strangulation is accomplished by this ligament.

The independent coverings of femoral hernia are: (a) peritoneum, (b) fascia, and (c) skin. The peritoneum is always a covering. The peritoneum forms the sac of the hernia. As the gut or viscus passes through the femoral canal it pushes the peritoneum before it. Femoral hernia forms gradually-probably always.

After passing through the canal the hernia is covered by the deep layer of superficial fascia (cribriform fascia). It is then covered by the superficial fascia, and finally by skin.

The coverings which the hernia receive from the canal are: 1. The femoral septum (at its internal mouth). 2. The femoral sheath (or external end of the canal).

The independent coverings are: 1. The peritoneum (or sac of the hernia). 2. The deep superficial fascia (cribriform fascia). 3. The superficial fascia. 4. The skin.

In operating few of these coverings can be recognized. But the one which requires attention is the sac. One may mistake it for the gut.

Femoral hernia has a habit of suddenly becoming strangulated, i. e., the venous circulation is suddenly obstructed, which ends in necrosis (gangrene). Taxis should only be practiced for fifteen to twenty minutes on femoral hernia, and then if reduction is impossible an operation should be performed.

Men have only two per cent of femoral hernia. Women have twice as much inguinal hernia as femoral. Hence, in one hundred women with hernia, thirty per cent would be femoral, sixty per cent would be inguinal, ten per cent would belong to other varieties. Few think

that women have twice as much inguinal hernia as femoral.

If one will sit down and carefully dissect the hernial openings (femoral and inguinal), it will surprise him to note their peculiarities in different individuals. Sometimes one can scarcely feel a depression by opening the abdomen and feeling the opening with the point of the index finger, at other times larger depressions are felt. The constant variation of intra-abdominal pressure must exercise a decided influence on these' potential openings.

This much can be said in regard to hernia, that its frequency is in direct proportion to individual exertions (muscular). Heavy lifters, athletes, etc., have hernia oftener than persons who lead less active lives. The anatomy simply yields to excessive intra-abdominal pressure. It is exactly similar to prolapse of the uterus or sacro-pubic hernia.

In sacro-pubic hernia the chief factor is intra-abdominal pressure. The second factor is deficient support of the sacral segment (the fixed portion of the pelvic floor). The third part is loss of tone in the pubic segment (the movable portion of the pelvic floor).

In femoral (or inguinal) hernia the loss of tone must arise in the elongation of the mesentery; for, in a normal person, the viscera will not pass through the hernial openings, as they have not sufficient length to their mesentery.

In hernia, then, we must have (1) dilated orifices, and (2) elongation of visceral attachments.

Legendre estimated that one person in one hundred and sixty-three have hernia.

Urethritis.

Inflammation of the urethra may be traumatic or idiopathic, specific or nonspecific, local or general. Among the more frequent causes of traumatic urethritis are direct violence from without applied to the perineum or penis, violent or excessive sexual intercourse, the introduction of instruments or corrosive substances, and the lodgment of foreign bodies carried in from without, or vesical or prostatic calculi, etc. It is usually of short duration, mild in character, and involves only a limited portion of the canal. The treatment demanded is rest,